Board 217 - Program Innovations AbstractDevelopment of an Evidence Based Critical Care Training Curriculum for General Surgery Residents using High Fidelity Simulation (Submission #532)

Abstract

Introduction/Background Simulation based medical education originated in the 17th century. It is thought to have begun with birthing training. More recent and familiar is simulation associated with aviation where deliberate preparation, execution and debriefing have improved flight safety and mission effectiveness. Our general surgery residency program utilizes simulation training for laparoscopic and endoscopic procedures. This is accomplished using mostly passive trainers, although more advanced high fidelity simulators are available and used on a limited basis. A need was identified for non-procedural critical care simulation in the curriculum. Implementation of this new training was limited by the lack of a well defined curriculum or evaluation device. The appropriate amount of time to allocate was similarly unclear. Review of the literature confirms that these are common issues in the field of medical simulation and in training programs across the country. Efforts nationwide to date can best be described as trial and error. Development of a curriculum for non-procedural simulation training is the basis of this project. The desire is to replace traditional experienced based training with a competency based model. The ultimate goal is to develop curricula and simulation techniques that improve patient care. Methods SimMan 3G (Laerdal Medical, Wappingers Falls, NY) was utilized for simulation. Initial efforts followed American College of Surgeons/Association of Program Directors in Surgery suggested scenarios. Subsequently, scenarios were locally developed and founded on basic educational theory. A specific knowledge gap was identified and targeted: critical care and volume resuscitation. Learner feedback was given in formal, detailed debrief sessions as well as via real time critique during or immediately after the training. Multiple issues were examined: number of physiologic abnormalities and patients to present, number of learners involved in each scenario, scenario length, moulage techniques, use of imaging, presentation of labs, verbal interaction with the manikin, latitude given to technicians during the scenario, assessment and feedback mechanisms and overall opinion of utility of simulation training. Data were captured via survey of learners and faculty. Objective learner assessment tools were developed and revised throughout the year. Video of the scenarios was reviewed by independent faculty, verifying initial assessments. Results: Conclusion Feedback from learners and faculty regarding the utility of simulation and its impact on clinical knowledge was universally positive. Both felt learner skills improved. Data obtained so far are insufficient to objectively comment on this opinion. Efforts to date result in the following Conclusions: 1) Scenarios/rooms should run 15-20 minutes each, focus on 2-3 physiologic abnormalities per patient and use up to 2 simultaneous patient simulators/mannequins; 2) Training should include 2 of these scenarios/rooms with 10 minute feedback for each; 3) Learners prefer individual versus group training; 4) Moulage should be kept very simple; 5) Imaging/Labs should be presented similar to hospital system (ie, printed, films, computer); 6) Verbally interacting with the manikin is paramount to realism; 7) Simulation technicians should understand the clinical situations and goals of training and be given latitude to tailor the simulation to the learner in real time. This dramatically improves realism; 8) Learner assessment tools must be brief and should use a combination of Likert scales, objective data and script concordance. They should be used for trending performance and not as the only feedback mechanism to the learner; 9) Debriefing is time consuming and the most difficult event to fit in to the training. Protracted review of tapes and discussion is difficult. Immediate brief feedback at the end of the scenario has worked best. Our simulation strategy continues to evolve. An ongoing project continues to focus on evidence based curriculum development and feedback techniques. This work has advanced the state of the art and improved upon current best practice for non-procedural high-fidelity simulation in general surgery training programs. Many questions remain the targets of future research.