Physical Realism of Simulation Training for Health Care in Low- and Middle-Income Countries-A Systematic Review

ABSTRACT

This systematic review was conducted, according to PRISMA standards, to examine the impact of the level of physical realism of simulation training on clinical, educational, and procedural outcomes in low- and middle-income countries (LMICs) as defined by the World Bank. A search from January 1, 2011 to January 24, 2023 identified 2311 studies that met the inclusion criteria including 9 randomized (n = 627) and 2 case-controlled studies (n = 159). Due to the high risk of bias and inconsistency, the certainty of evidence was very low, and heterogeneity prevented any metaanalysis. We observed limited evidence for desirable effects in participant satisfaction and confidence, but no significant difference in skills acquisition and performance in the clinical practice environment. When considering the equivocal evidence and cost implications, we recommend the use of lower physical realism simulation training in LMIC settings. It is important to standardize outcomes and conduct more studies in lower income settings.

Cross-sectional study in Madagascar demonstrates efficacy of virtual mentoring and flipped classroom modifications of neonatal resuscitation programme Helping Babies Breathe

AIM

The Covid-19 pandemic necessitated virtual adaptation of the neonatal resuscitation programme Helping Babies Breathe (HBB). This study assessed one such virtually mentored and flipped classroom modification in Madagascar.

METHODS

A cross-sectional study was performed in September 2021 and May 2022. Healthcare providers were identified by local collaborating organisations. United States-based master trainers collaborated with local trainers on virtually mentored trainings followed by independent trainings. Master trainers were available for consultation via Zoom during the virtual training. A flipped classroom modification and traditional didactic method were compared. Primary outcomes were knowledge and skill acquisition, evaluated by written assessments and objective structured clinical examinations.

RESULTS

Overall, 97 providers completed the curriculum. Written assessment scores improved in both training models (traditional - 74.8% versus 91.5%, p<0.001; flipped classroom - 89.7% versus 93.6%, p<0.05). There was no significant difference among written assessment scores (92.8% versus 91.5%, p=0.62) and significantly higher objective structured clinical examination scores (97.3% versus 89.5%, p<0.001) for the independent training compared to the virtually mentored training.

CONCLUSION

The virtually mentored HBB training was followed by a successful independent training as measured by participant knowledge and skill acquisition, supporting the efficacy of virtual dissemination.

Cardiopulmonary Resuscitation During Simulated Pediatric Interhospital Transport: Lessons Learned From Implementation of an Institutional Curriculum

INTRODUCTION

Little is known about cardiopulmonary resuscitation (CPR) quality during pediatric interhospital transport; hence, our aim was to investigate its feasibility.

METHODS

After implementing an institutional education curriculum on pediatric resuscitation during ambulance transport, we conducted a 4-year prospective observational study involving simulation events. Simulated scenarios were (1) interhospital transport of a child retrieved in cardiac arrest (Sim1) and (2) unanticipated cardiac arrest of a child during transport (Sim2). Cardiopulmonary resuscitation data were collected via Zoll RSeries defibrillators. Performance was evaluated using age-appropriate American Heart Association (AHA) Guidelines. Video recordings were reviewed for qualitative thematic analysis.

RESULTS

Twenty-six simulations were included: 16 Sim1 [mannequins: Laerdal SimMan 3G (n = 13); Gaumard 5-year-old HAL (n = 3)] and 10 Sim2 [Gaumard 1-year-old HAL (n = 8); Laerdal SimBaby (n = 2)]. Median (IQR) CPR duration was 18 minutes 23 seconds (14-22 minutes), chest compression rate was 112 per minute (106-118), and fraction (CCF) was 1 (0.9-1). Five hundred eight 60-second resuscitation epochs were evaluated (Sim1: 356; Sim2: 152); 73% were AHA compliant for rate and 87.8% for CCF. Twenty-four minutes (4.7%) had pauses more than 10 seconds. One hundred fifty seven Sim1 epochs (44.1%) met criteria for excellent CPR (AHA-compliant for rate, depth, and CCF). Rates of excellent CPR were higher for learner groups with increased simulation and transport experience (59.1% vs. 35.3%, P < 0.001). Thematic analysis identified performance-enhancing strategies, stemming from anticipating challenges, planning solutions, and ensuring team's shared mental model.

CONCLUSIONS

High-quality CPR may be achievable during pediatric interhospital transport. Certain transport-specific strategies may enhance resuscitation quality. Learners' performance improved with simulation and transport experience, highlighting ongoing education's role.

A qualitative study of barriers and facilitators to pediatric early warning score (PEWS) implementation in a resource-limited setting

Objectives

Globally, pediatric hospitals have implemented Pediatric Early Warning Scores (PEWS) to standardize escalation of care and improve detection of clinical deterioration in pediatric patients. This study aims to utilize qualitative methodology to understand barriers and facilitators of PEWS implementation at Philippine Children's Medical Center (PCMC), a tertiary care hospital in Manila, Philippines.

Methods

Semi-structured interviews querying current processes for clinical monitoring, Pediatric Intensive Care Unit (PICU) transfer, and clinician attitudes towards PEWS implementation were audio recorded. In-person hospital observations served to triangulate interview findings. The Systems Engineering Initiative for Patient Safety (SEIPS) framework guided content coding of interviews to characterize work systems, processes, and outcomes related to patient monitoring and care escalation. Thematic coding was performed using Dedoose software. This model allowed identification of barriers and facilitators to PEWS implementation.

Results

Barriers within PCMC workflow included: limited bed capacity, delay in referral, patient overflow, limited monitoring equipment, and high patient to staff ratio. Facilitators of PEWS implementation included support for PEWS adaptation and existence of systems for vital sign monitoring. Observations by study personnel confirmed validity of themes.

Conclusion

Utilizing qualitative methodology to understand barriers and facilitators to PEWS in specific contexts can guide implementation at resource-limited hospitals.

Time Management and Task Prioritization Curriculum for Pediatric and Internal Medicine Subinternship Students

INTRODUCTION

As a physician, it is important to develop time management and task prioritization skills early to promote future career success. In medical education, there is minimal structured time to teach these skills prior to residency. Stephen Covey's Time Management Matrix Technique (TMMT) is one strategy that can be used to develop these skills. This technique categorizes tasks into a four-quadrant table based on importance and urgency. Using this technique as a model, the authors developed a workshop for medical students on an inpatient pediatric or internal medicine subinternship.

METHODS

Prior to the workshop, students read an article and completed a survey and two self-directed exercises. The exercises asked students to create a list of tasks, develop an individualized TMMT model, and review specialty-specific patient cases. The workshop consisted of discussions on the presession work and group exercises on prioritizing tasks and responding to patient-related pages. Students evaluated the curriculum after the workshop with a survey.

RESULTS

Most participants (82%) strongly agreed or agreed that the workshop improved their ability to manage time effectively and prioritize tasks on a clinical rotation. There was a statistically significant increase in both median time management and task prioritization confidence scores after completion of the workshop (p < .05).

DISCUSSION

This workshop provides one strategy that can be implemented within undergraduate medical education to enhance time management skills prior to residency. Future studies should be aimed at evaluating these skills within the clinical setting.

Addressing Trauma and Building Resilience in Children and Families: Standardized Patient Cases for Pediatric Residents

INTRODUCTION

Adverse childhood experiences (ACEs) and trauma are common and can negatively impact children's health. Standardized patient (SP) learning may provide trainees with knowledge and skills to screen for and manage ACEs, apply trauma-informed care approaches, and teach resilience strategies.

METHODS

With content experts, we developed three SP cases based on common clinical encounters, as well as didactic and debriefing materials. Case 1 focused on somatic symptoms in an adolescent with ACEs, case 2 focused on an ACE disclosure by a parent, and case 3 focused on de-escalation. The workshop required facilitators, SPs, simulation exam room and meeting space, and audiovisual equipment. It lasted 4 hours and included an orientation (1 hour), the three SP cases (totaling 2 hours), and group debriefing (1 hour).

RESULTS

We conducted five identical workshops with 22 pediatric residents. Participants responded favorably to case fidelity and applicability to their clinical work. Resident mean self-assessment scores improved significantly from baseline. Specifically, we assessed comfort with inquiring about and discussing ACEs, explaining the health impacts of trauma, identifying protective factors, resilience counseling, and de-escalation. Over 90% of responses indicated that residents were likely to apply what they had learned to their clinical practice.

DISCUSSION

These findings demonstrate that our SP cases were well received and suggest that such curricula can help pediatric residents feel more prepared to address trauma and promote resilience. Future work will assess these outcomes, as well as behavior change, in a larger sample to further substantiate these promising findings.

A structured genetics rotation for pediatric residents: an important educational opportunity

PURPOSE

As the integral role of genetics in health and disease becomes increasingly understood, pediatricians must incorporate genetic principles into their care of patients. Structured exposure to genetics during residency may better equip future pediatricians to meet this goal.

METHODS

Pediatric interns in the Johns Hopkins pediatric residency program have the option to spend one week immersed in clinical genetics by attending outpatient clinics and seeing inpatient consults. A pretest assessing clinical genetics knowledge is given before the rotation and compared with an identical post-test. Interns have a "scavenger hunt" to introduce genetic resources useful to pediatricians and complete a logbook of patient experiences. An evaluation is completed at the end of the rotation.

RESULTS

Since the selective started in July 2016, 50 interns have participated. Average pretest score was 2.5/5 compared with a post-test score of 4.3/5, p < 0.0001. Interns saw on average ten patients and four different diagnoses. Overall evaluation was 4.4 on a 5-point scale, 5 being "excellent."

CONCLUSION

This experience suggests that a structured rotation in genetics provides pediatric interns with an opportunity to learn basic clinical genetics knowledge and skills and see patients whom they may otherwise not encounter during residency.

A Standardized Needs Assessment Tool to Inform the Curriculum Development Process for Pediatric Resuscitation Simulation-Based Education in Resource-Limited Settings

INTRODUCTION

Under five mortality rates (UFMR) remain high for children in low- and middle-income countries (LMICs) in the developing world. Education for practitioners in these environments is a key factor to improve outcomes that will address United Nations Sustainable Development Goals 3 and 10 (good health and well being and reduced inequalities). In order to appropriately contextualize a curriculum using simulation, it is necessary to first conduct a needs assessment of the target learner population. The World Health Organization (WHO) has published a tool to assess capacity for emergency and surgical care in LMICs that is adaptable to this goal.

MATERIALS AND METHODS

The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was modified to assess pediatric resuscitation capacity in clinical settings in two LMICs: Uganda and Myanmar. Modifications included assessment of self-identified learning needs, current practices, and perceived epidemiology of disease burden in each clinical setting, in addition to assessment of pediatric resuscitation capacity in regard to infrastructure, procedures, equipment, and supplies. The modified tool was administered to 94 respondents from the two settings who were target learners of a proposed simulation-based curriculum in pediatric and neonatal resuscitation.

RESULTS

Infectious diseases (respiratory illnesses and diarrheal disease) were cited as the most common causes of pediatric deaths in both countries. Self-identified learning needs included knowledge and skill development in pediatric airway/breathing topics, as well as general resuscitation topics such as CPR and fluid resuscitation in shock. Equipment and supply availability varied substantially between settings, and critical shortages were identified in each setting. Current practices and procedures were often limited by equipment availability or infrastructural considerations.

DISCUSSION AND CONCLUSION

Epidemiology of disease burden reported by respondents was relatively consistent with WHO country-specific UFMR statistics in each setting. Results of the needs assessment survey were subsequently used to refine goals and objectives for the simulation curriculum and to ensure delivery of pragmatic educational content with recommendations that were contextualized for local capacity and resource availability. Effective use of the tool in two different settings increases its potential generalizability.

Adapting to a US Medical Curriculum in Malaysia: A Qualitative Study on Cultural Dissonance in International Education

Context

Minimal research has examined the recent exportation of medical curricula to international settings. Johns Hopkins University School of Medicine in Baltimore, USA partnered with Perdana University Graduate School of Medicine in Kuala Lumpur, Malaysia and implemented the same curriculum currently used at Johns Hopkins University to teach medical students at Perdana University. This study aimed to explore the perspectives of first-year medical students at Perdana University, focusing on issues of cultural dissonance during adaptation to a US curriculum.

Methods

In-depth semi-structured interviews with the inaugural class of first-year students (n=24) were conducted, audio-recorded, and transcribed. Two reviewers independently coded and analyzed the qualitative data for major themes.

Results

The most prominent themes identified were the transition from a “passive” to an “active” learning environment and the friendliness and openness of the professors. Students noted that “[Perdana University] is a whole new, different culture and now we are adapting to the culture.” Being vocal during classes and taking exams based on conceptual understanding and knowledge application/integration proved to be more challenging for students than having classes taught entirely in English or the amount of material covered.

Discussion

This study reinforced many cultural education theories as it revealed the major issues of Malaysian graduate students adapting to a US-style medical curriculum. Despite coming from a collectivistic, Confucian-based cultural learning background, the Malaysian students at Perdana University adopted and adapted to, and subsequently supported, the US learning expectations.

Pediatric Emergency Care in Disaster-Affected Areas: A Firsthand Perspective after Typhoons Bopha and Haiyan in the Philippines

Disasters are defined as man-made or natural causes that disrupt a population and cause widespread human, material, economic, or environmental losses, exceeding that population's capacity to cope using its own resources. This review highlights the epidemiology and disease patterns in disasters, with specific application to the care of children in the austere environments created in the aftermath of disasters. The review also attempts to describe the experience from a firsthand field hospital perspective of a multinational team in caring for patients in the aftermath of two natural disasters in the Philippines, during both Typhoon Bopha and Typhoon Haiyan. In doing so, we will place these experiences in the context of the current literature on the subject of pediatric management during disaster emergencies and describe lessons learned to refine team approaches and patient care methodologies. The review also discusses methods for improvement in emergency preparedness for disasters, with specific mention of the roles of telemedicine and just-in-time simulation training, when feasible. Lastly, it will review the importance of community and military collaboration and planning for aftercare post-departure of foreign medical teams.

Pediatric Resuscitation Education in Low-Middle-Income Countries: Effective Strategies for Successful Program Development

Despite established international guidelines, there is considerable variability in the quality of resuscitative care received by critically ill children in low-middle-income countries. While this problem is certainly multifactorial, education of health care workers is an important determinant of care quality. This article will discuss approaches to health care worker education in pediatric resuscitation in low-middle-income countries, with emphasis on aspects of educational programs that may contribute to positive educational and clinical outcomes.

Building consensus for the future of paediatric simulation: a novel ‘KJ Reverse-Merlin’ methodology

Objectives

This project aims to identify guiding strategic principles to optimise simulation-based educational impact on learning, patient safety and child health.

Methods

Study participants included 39 simulation experts who used a novel ‘KJ Reverse-Merlin’ consensus process in the systematic identification of barriers to success in simulation, grouped them in themes and subsequently identified solutions for each theme.

Results

193 unique factors were identified and clustered into 6 affinity groups. 6 key consensus strategies were identified: (1) allocate limited resources by engaging health systems partners to define education and research priorities; (2) conduct and publish rigorous translational and cost-effectiveness research; (3) foster collaborative multidisciplinary research and education networks; (4) design simulation solutions with systems integration and sustainability in mind; (5) leverage partnerships with industry for simulation, medical and educational technology; (6) advocate to engage the education community, research funding agencies and regulatory bodies.

Conclusions

Simulation can be used as a research, quality improvement and or educational tool aimed at improving the quality of care provided to children. However, without organisation, strategy, prioritisation and collaboration, the simulation community runs the risk of wasting resources, duplicating and misdirecting the efforts.

Identification of Barriers to Pediatric Care in Limited-Resource Settings: A Simulation Study

OBJECTIVES

Eighty percent of the 10 million annual deaths in children aged <5 years in developing countries are estimated to be avoidable, with improvements in education for pediatric emergency management being a key factor. Education must take into account cultural considerations to be effective. Study objectives were: (1) to use simulation to identify factors posing barriers to patient care in limited resource settings (LRS); and (2) to understand how simulations in LRS can affect communication and decision-making processes.

METHODS

A qualitative study was conducted at 17 different sites in 12 developing countries in Asia, Latin America, and Africa. Data from observations of 68 in situ simulated pediatric emergencies were coded for thematic analysis. Sixty-two different "key informants" were interviewed regarding perceived benefit of simulations.

RESULTS

Coding of observations and interviews yielded common themes: impact of culture on team hierarchy, impact of communication and language barriers on situational awareness, systematic emergency procedures, role delineation, shared cognition and resource awareness through simulation, logistic barriers to patient care, and use of recognition-primed decision-making by experienced clinicians. Changes in clinical environments were implemented as a result of simulations.

CONCLUSIONS

Ad hoc teams in LRS face challenges in caring safely for patients; these include language and cultural barriers, as well as environmental and resource constraints. Engaging teams in simulations may promote improved communication, identification of systems issues and latent threats to target for remediation. There may be a role for training novices in use of recognition-primed or algorithmic decision-making strategies to improve rapidity and efficiency of decisions in LRS.

How do gender and anxiety affect students' self-assessment and actual performance on a high-stakes clinical skills examination?

PURPOSE

Research suggests that medical students are not accurate in self-assessment, but it is not clear whether students over- or underestimate their skills or how certain characteristics correlate with accuracy in self-assessment. The goal of this study was to determine the effect of gender and anxiety on accuracy of students' self-assessment and on actual performance in the context of a high-stakes assessment.

METHOD

Prior to their fourth year of medical school, two classes of medical students at Johns Hopkins University School of Medicine completed a required clinical skills exam in fall 2010 and 2011, respectively. Two hundred two students rated their anxiety in anticipation of the exam and predicted their overall scores in the history taking and physical examination performance domains. A self-assessment deviation score was calculated by subtracting each student's predicted score from his or her score as rated by standardized patients.

RESULTS

When students self-assessed their data gathering performance, there was a weak negative correlation between their predicted scores and their actual scores on the examination. Additionally, there was an interaction effect of anxiety and gender on both self-assessment deviation scores and actual performance. Specifically, females with high anxiety were more accurate in self-assessment and achieved higher actual scores compared with males with high anxiety. No differences by gender emerged for students with moderate or low anxiety.

CONCLUSIONS

Educators should take into account not only gender but also the role of emotion, in this case anxiety, when planning interventions to help improve accuracy of students' self-assessment.

Telephone referrals by junior doctors: a randomised controlled trial assessing the impact of SBAR in a simulated setting

OBJECTIVE

To determine whether exposing junior doctors to Situation, Background, Assessment, Recommendation (SBAR) improves their telephone referrals. SBAR is a standardised minimum information communication tool.

METHODS

A randomised controlled trial with participants and rating clinicians both blinded to group allocation. Hospital interns from a 2-year period (2006-2007) participated in two simulated clinical scenarios which required them to make telephone referrals. The intervention group was educated in SBAR between scenarios. Pre and post intervention telephone referrals were recorded, scored and compared. Six-month follow-up and year group comparisons were also made. An objective rating score measured the presence of specific 'critical data' communication elements on a scale of 1-12. Qualitative measures of global rating scores and participant self-rated scoring of performance were recorded. Time to 'first pitch' (the intern's initial speech) was also recorded.

RESULTS

Data were available for 66 interns out of 91 eligible. SBAR exposure did not increase the number of communication elements presented; objective rating scores were 8.5 (IQ 7.0-9.0) for SBAR and 8.0 (IQ 6.5-8.0) for the control group (p=0.051). Median global rating scores, designed to measure 'call impact', were higher following SBAR exposure (SBAR: 3.0 (IQR 2.0-4.0); control: 2.0 (IQ 1.0-3.0); p=0.003)). Global rating scores improved as time to 'first pitch' duration decreased (p=0.001). SBAR exposure did not improve time to 'first pitch' duration.

CONCLUSION

In this simulated setting exposure to SBAR did not improve telephone referral performance by increasing the amount of critical information presented, despite the fact that it is a minimum data element tool. SBAR did improve the 'call impact' of the telephone referral as measured by qualitative global rating scores.

Training hospital providers in basic CPR skills in Botswana: acquisition, retention and impact of novel training techniques

OBJECTIVE

Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. We hypothesized that both existing and novel CPR training programs significantly impact skills of hospital-based healthcare providers (HCP) in Botswana.

METHODS

HCP were prospectively randomized to 3 training groups: instructor led, limited instructor with manikin feedback, or self-directed learning. Data was collected prior to training, immediately after and at 3 and 6 months. Excellent CPR was prospectively defined as having at least 4 of 5 characteristics: depth, rate, release, no flow fraction, and no excessive ventilation. GEE was performed to account for within subject correlation.

RESULTS

Of 214 HCP trained, 40% resuscitate ≥ 1/month, 28% had previous formal CPR training, and 65% required additional skills remediation to pass using AHA criteria. Excellent CPR skill acquisition was significant (infant: 32% vs. 71%, p<0.01; adult 28% vs. 48%, p<0.01). Infant CPR skill retention was significant at 3 (39% vs. 70%, p<0.01) and 6 months (38% vs. 67%, p<0.01), and adult CPR skills were retained to 3 months (34% vs. 51%, p=0.02). On multivariable analysis, low cognitive score and need for skill remediation, but not instruction method, impacted CPR skill performance.

CONCLUSIONS

HCP in resource-limited settings resuscitate frequently, with little CPR training. Using existing training, HCP acquire and retain skills, yet often require remediation. Novel techniques with increased student: instructor ratio and feedback manikins were not different compared to traditional instruction.

Medical student and faculty perceptions of volunteer outpatients versus simulated patients in communication skills training

PURPOSE

To determine whether medical students and faculty perceive differences in the effectiveness of interactions with real patients versus simulated patients (SPs) in communication skills training.

METHOD

In 2008, the authors recruited volunteer outpatients (VOs) from the Johns Hopkins University School of Medicine internal medicine practice to participate in communication skills training for all first-year medical students. VOs and SPs were assigned to clinic rooms in the simulation center. Each group of five students and its preceptor rotated through randomly assigned rooms on two of four session days; on both days, each student interviewed one patient for 15 minutes, focusing on past medical and family history or social history. Patients used their own histories, not scripts; students were not blinded to patient type. Students and faculty then rated aspects of the interview experience. Generalized linear latent and mixed-models analysis was used to compare ratings of communication skills training with VOs versus SPs.

RESULTS

All 121 first-year students participated in 242 interviews, resulting in 237 usable questionnaires (98%). They rated their experiences with VOs significantly higher than those with SPs on comfort, friendliness, amount of learning, opportunity to build relationships, and overall meeting of communication skills training needs. The 24 faculty preceptors' ratings of the 242 interactions did not differ significantly between VOs and SPs.

CONCLUSIONS

Use of VOs was well received by students and faculty for teaching communication skills. Expanding and further studying VOs' participation will allow greater understanding of their potential role in communication skills training of preclinical medical students.

Myosin binding protein C is differentially phosphorylated upon myocardial stunning in canine and rat hearts — Evidence for novel phosphorylation sites

Myocardial stunning is the transient cardiac dysfunction that follows brief episodes of ischemia and reperfusion without associated myocardial necrosis. Currently, there is limited knowledge about its cellular and biochemical mechanisms. In order to better understand the underlying mechanisms of contractile dysfunction associated with the stunning, comprehensive proteomic studies using 2-D DIGE were performed using a regional stunning model in canine heart. Cardiac myosin binding protein C (cMyBP-C), a regulatory myofilament protein associated with the thick filament, and nebulette, a thin filament associated protein, were differentially expressed. Phosphoprotein specific staining indicated both protein changes were due to phosphorylation. Subsequent phosphorylation mapping of canine cMyBP-C using IMAC and MS/MS identified five phosphorylation sites, including three novel sites. In order to further evaluate this finding in a different model, cMyBP-C phosphorylation was examined in a rat model of global stunning. In the rat model, stunning was associated with increased phosphorylation of cMyBP-C at a critical calcium/calmodulin-dependent kinase II site, and the increased phosphorylation was largely inhibited when stunning was prevented by either ischemic preconditioning or reperfusion in the presence of low-calcium buffer. These data indicate cMyBP-C phosphorylation plays an important role in myocardial stunning.