Hi-fidelity Simulation Research Articles

124 The Microsurgical Learning Curve: Can We Make the First Steps Faster and Safer; A Cadaveric Study with A Novel Principle of Learning

Abstract Aim Learning anew surgical technique can be a daunting experience for both the teacher and learner. Raising free flaps is a complex process, and our aim is to find out whether using Hi-fidelity simulation on cadavers can make the learning faster and safer. Method We used fresh frozen cadavers according to our local protocols. In the first stage of the study, we used 4 upper limbs in the first instance using different dye techniques. We use these in an international course and obtain feedback from the trainees. Results To a novel learner, we found that using a bright green dye was the important factor in making the first steps of learning easier and faster. This is perhaps due to the confounding information when raising the flap. We found that it made understanding the concept of free flap raising much faster when clarified with colour. It also made anticipating the steps easier when identifying the perforators. To an experienced trainee/consultant: We found teaching the concept of perforators easier, the ease of finding the perforators would raise confidence of the novel trainees. They will be able to conceptualize the principles of flap raising much faster. They believed it would also make them quicker at anticipating steps of the procedure. Conclusions Learning is an incredible process that we still have to better control and understand. Using simple tricks such as colour changes can make initial learning faster, which means cheaper and safer

Do innovative immersive virtual reality simulation videos have a role to play in teaching non-technical skills and increasing preparedness for clinical placements for medical students?

Teaching non-technical skills (NTS) is an important part of the undergraduate medical curriculum. Resource intensive high-fidelity simulation has an established role in this. Alternative methods of deliveringlarge scalesimulation-based education should be considered to help further improve NTS and preparedness for clinical placements of medical students. Emerging technologies such as immersive virtual reality (VR) may have a role in this. To assess if a VR simulation-based teaching programme enhances understanding of NTS and preparedness for clinical placements in medical students at the University of Liverpool. A VR simulation-based teaching programme, consisting of 4 sessions of lecture-based simulation and a hi-fidelity simulation session was delivered to 3 rdyear medical students. The lecture-based sessions used pre-recorded, immersive clinical scenarios developed by the School of Medicine, with a focus on NTS. The hi-fidelity simulation session was delivered by local hospital trusts. A survey was sent to all students to assess theirunderstanding of key NTS:decision making, task prioritisation and delegation and how the clinical environment works. Preparedness for clinical placement and confidence in the clinical environment was also assessed. A focus group further explored how students felt towards these NTS, with subsequent thematic analysis. Results:101/281 students responded to the survey reporting a greater understanding in all NTS assessed.Students also described feeling better prepared for clinical placements. The focus group reported the programme provided a 'safe space' for learning alongside increasing understanding of role modelling and self-awareness. Discussion:Utilising emerging technology alongside hi-fidelity simulation increased students' exposure to the clinical environment and enabled exploration ofNTSby students. Additional work with larger focus groupswill be required to further validate our results.Whilst restrictions are limiting clinical exposure due to theCOVID-19 pandemic, we propose that VR simulation-based teaching programmes could provide an alternativeeducational tool.

TF14 Development of a Distal Radius Fracture Mastery Learning Class

Successful reduction and treatment of a patient with a distal radius fracture is an essential skill for the practice of an emergency physician, yet, the graduating emergency physician may have had minimal opportunities to learn the procedure as a resident. Limited opportunities make realistic simulation important, but simulation without purpose and feedback does not lead to effective practice. Mastery learning is a type of intensive coursework for procedural learning that stresses asynchronous preparation, deliberate practice, and close oversight and assessment to ensure learning. Mastery learning has been rigorously studied and shown to be effective in improving learning and even patient outcomes for central line placement. However, mastery learning necessitates a hi-fidelity simulation experience for full learner benefit. Our objectives are: to develop a mastery learning curriculum and hi fidelity model for distal radius fractures; to evaluate the success of the curriculum with regards to individual education; and to determine the strength of an association between improved knowledge or competence and trends in treatments of distal radius fractures in the Stanford ED. We performed a needs assessment using a survey instrument to determine resident level of comfort with the steps of the reduction of the distal radius fracture. We have built and iterated a 3D printed model of a distal radius fracture that simulates fracture exam and reduction. Curriculum and checklists are being developed with orthopedic surgery input. Assessment of the curriculum will include knowledge tests and surveys. Evaluation of behavior change will include resident procedure logs and trends in care of distal radius fractures in the ED. Needs assessment data has shown a gap in resident knowledge and perceived competence in the reduction of distal radius fractures. We have built a 3D distal radius fracture model that is capable of hi fidelity simulation for a mastery learning class. We have created a curriculum and mastery learning checklist with multidisciplinary input. The reduction of a distal radius fracture is a crucial skill for emergency medicine residents. Current confidence in training is lacking. We have developed a mastery learning course to optimize training. We expect changes in resident knowledge, competence, and behavior regarding this skill, which we will measure throughout the implementation phase.

Effect of Monitor Placement on Situational Awareness and Visual Attention in Simulated Neonatal Resuscitations

Abstract BACKGROUND Decision-making in neonatal resuscitation depends on clinical evaluation, oxygen saturation and heart-rate. However, the position of vital signs monitors varies between institutions and might lead to obstructed or difficult to see displays, which might affect Health Care Provider (HCP) performance. OBJECTIVES To compare Situation Awareness (SA), Neonatal Resuscitation (NRP) checklist score, Visual Attention (VA) and participant satisfaction during simulated neonatal resuscitations using two vital signs monitors locations. DESIGN/METHODS NRP-trained HCPs were recruited from a tertiary Neonatal Intensive Care Unit and randomized to either central (eye-level on the radiant warmer) or peripheral (left of the warmer) monitor placement. Following an orientation scenario, each HCP lead a resuscitation requiring intubation and chest compressions with a high-fidelity manikin (Newborn HAL, Gaumard Scientific, Miami, FL) and a standardized assistant. Each scenario was paused at 3 predetermined points and the HCP was asked 5 SA questions at each pause, per the Situation Awareness Global Assessment Tool (SAGAT) format. Simulations were video-recorded to analyze SAGAT responses and performance rating using a modified NRP checklist. VA was recorded using eye-tracking glasses (Tobii Pro, Tobii Technology Inc., Falls Church, VA) worn by participants. Statistical analysis was performed using Mann-Whitney U test. A post-simulation survey examined user preference. RESULTS We randomized 30 HCPs; all were analyzed for SA and NRP checklist scores. Twenty-two eye-tracking recordings were of sufficient quality and analyzed. SAGAT scores (median 11/15 vs. 12/15, p=0.52) and NRP Checklist Scores (median 46/50, p=0.75) were similar between groups. Distribution of VA was also similar in both groups. In the post-simulation survey, all HCPs found central monitor placement convenient, compared with only 8/15 in peripheral placement. CONCLUSION During simulated neonatal resuscitation, HCPs found central monitor placement more convenient. However, no differences in accuracy of situation awareness responses, NRP checklist scores, or visual attention were found. Hi-fidelity simulation, SAGAT, and eye-tracking can be used to evaluate physical ergonomics of neonatal resuscitation.

Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol

Breaking bad news (BBN) in the emergency department (ED) is a common occurrence. This is especially true for an emergency physician (EP) as there is little time to prepare for the event and likely little or no knowledge of the patients or family background information. At our institution, there is no formal training for EP residents in delivering bad news. We felt teaching emergency medicine residents these communication skills should be an important part of their educational curriculum. We describe our experience with a defined educational program designed to educate and improve physician’s confidence and competence in bad news and death notification. A regularly scheduled 5-h grand rounds conference time frame was dedicated to the education of EM residents about BBN. A multidisciplinary approach was taken to broaden the prospective of the participants. The course included lectures from different specialties, role playing for three short scenarios in different capacities, and hi-fidelity simulation cases with volatile psychosocial issues and stressors. Participants were asked to fill out a self-efficacy form and evaluation sheets. Fourteen emergency residents participated and all thought that this education is necessary. The mean score of usefulness is 4.73 on a Likert Scale from 1 to 5. The simulation part was thought to be the most useful (43%), with role play 14%, and lecture 7%. We believe that teaching physicians to BBN in a controlled environment is a good use of educational time and an important procedure that EP must learn.

Simulation in a high stakes clinical performance exam

Background:Hi-fidelity simulation is becoming accepted as a teaching tool for medical providers. Advanced simulations allow educators to test difficult clinical scenarios. The goal of this study was to test the diagnostic and treatment skills of a third-year medical student faced with a simulated patient having evidence of a stable pneumothorax. Students are then expected to evaluate the teaching simulation in comparison to traditional methods.Methods:The case was one of a 12 cases in the “high stakes” Clinical Performance Exam. The patient with evidence of a stable pneumothorax was chosen to evaluate both diagnostic abilities and decision making in therapeutic options. Students were assessed using a university-wide standardized checklist: diagnosis, management, and interaction with the simulator. Immediately following the simulation, the students evaluated the experience.Results:The exam was given to 117 students. The correct diagnosis was made by 115/117 (98%). Treatment was considered acceptable in a majority of students, Send patient to the Emergency Department 77%, Oxygen 26% and Analgesia 39%. The follow-up survey completed by 78% of the students revealed the students felt comfortable with the simulators, but had concerns about the exam. Students liked the simulator as an educational tool 88% of the time.Conclusions:Simulation was used in a year-end exam and majority of students chose the correct diagnosis and treatment plan. It was also found that a significant percentage of students performed an unnecessary and potentially harmful procedure. The survey revealed that students were concerned about distractions and realism, but overall expressed desire for more education using simulation.

Introduction of hi-fidelity simulation techniques as an ideal teaching tool for upcoming emergency medicine and trauma residency programs in India

Emergency medicine (EM) residency programs are a new concept to India. As these programs develop in India the need for effective teaching tools for skills education will rise. A high fidelity simulation workshop was conducted with a intent to expose current residents posted in emergency departments (EDs) to the concept of simulation technology. The participants were subjected to scenarios which tested their core competencies, medical knowledge, and procedural skills using simulation technology. 50 residents were tested over 5 days and an overall satisfaction score and personal comments were assessed to rate the performance of this study. A pre- and post simulation survey was done. Results showed that participants felt that their understanding of communication of expectations increased from 38% fair or good to 76% very good or best. The frequency in which they thought they would ask for help increased from 36% fair or good to 88% very good or best. It was found that students had increased their confidence to challenge a questionable order from a superior from 48% occasionally or half of the time to 76% who would do it the majority of the time or always. In the post-survey, 80% would the majority of the time or always admit that they did not know something from 46% who stated they would only do it occasionally or half of the time. We concluded that simulation as a tool for teaching unknown and stressful conditions of ED naturally pair. Resident core competencies can be taught and evaluated more effectively in the simulation lab in a controlled, safe, and collegial manner.

Using Work Domain Analysis to Analyse Perfusionists' Conceptualisation Processes during Routine and Failure Cardio-Pulmonary Bypass Scenarios: Preliminary Outcomes Using Markov Chain Analysis

Cardio-pulmonary bypass (CPB) involves the maintenance of whole body perfusion during cardiac surgery. While CPB is safe, emergencies do occur and perfusionists are expected to respond appropriately. However, perfusionists' training programs appear to be underdeveloped. In addition, there appears to be little understanding about how perfusionists conceptualise their work domain. This paper presents a work domain analysis-based (WDA) protocol for analysing perfusionists conceptualisations. A WDA of the CPB is presented. A hi-fidelity simulation environment with a video-cued recall interview data collection protocol is described and a Markov Chain analysis of verbal protocols is outlined using two participant data sets. We conclude that with further participant data analysis this novel approach offers promising insights into conceptualisation processes and exposes addition procedural, organisational and engineering issues that may need to be included in curriculum development.