High-fidelity Simulation Training Research Articles

Development of a Manual for a Customizable, Low Tech, High Fidelity Simulation Training Program to Prepare Civilian Hospitals for Mass Casualty Incidents

Journal of the American College of Surgeons 227(4):p e182-e183, October 2018. | DOI: 10.1016/j.jamcollsurg.2018.08.497

Technical Advances in the Field of ECMO.

Although the fundamentals of extracorporeal membrane oxygenation (ECMO) have not changed in 3 decades, the technical elements continue to improve and have evolved from an assemblage of individual components to more integrated systems with added features, enhanced safety, and improved maneuverability. The introduction of polymethylpentene (PMP) fiber technology has expanded the development of artificial membranes that have low resistance, are more biocompatible, and can be used for extended durations. Extracorporeal carbon dioxide removal techniques continue to be enhanced as stand alone technology and modified renal dialysis systems are introduced. Research continues in the development of compact and wearable artificial lungs that are intended to support patients for prolonged periods (eg, patients awaiting lung transplantation). The use of high-fidelity simulation training has become a standard and important method for reinforcing technical skills, refining troubleshooting sequences, and enhancing team interactions. Modifications to mannequins and ECMO systems coupled with clinical and physiologic scenarios will help achieve greater realism and enhance learning. ECMO technology continues to improve, with adaptability and versatility being essential attributes.

Editorial introductions

Current Opinion in Anesthesiology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of anesthesiology is divided into 15 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Ken B. JohnsonKen B. JohnsonKen B. Johnson, MD is an anesthesiologist at the University of Utah, USA. His clinical interests are in acute pain management and anesthetic drug pharmacology. He is the Vice Chair for Research in the Department of Anesthesiology. His research interests are in anesthetic drug interactions, developing pain biomarkers, and medical device development to better capture adverse respiratory events. Dr Johnson has received extramural support from government, foundations, and industry to support his work. He has enjoyed collaborating with researchers in bioengineering, neuroscience, and pharmacology. Dr Johnson's education interests are in screen-based and high-fidelity simulation. He serves as the Co-Director of the Center for Simulation within the Department of Anesthesiology. He directs simulation courses that meet selected requirements for Maintenance of Certification in Anesthesia established by the American Board of Anesthesiology. He is a member of the team that has developed both online and high-fidelity simulation training for moderate and deep sedation endorsed by the American Society of Anesthesiologists. By way of professional service, Dr Johnson is a Section Editor for Anesthesia and Analgesia, a member of the American Society of Anesthesiologist's Simulation Education Editorial Board, and a Part II examiner (oral board examiner) for the American Board of Anesthesiologists. He also serves on the American Board of Anesthesiologists Observed Structured Clinical Examination Development Committee. Mark S. WeissMark S. WeissMark S. Weiss is an Assistant Professor of Anesthesiology and Critical Care at the University of Pennsylvania, USA. He is the Section Chief of Inpatient Endoscopy, and works both in the Operating Room and Non-Operating Room setting. Dr Weiss earned his medical degree from the University of Cincinnati, USA. He completed his Residency at Yale University, USA, after which he completed a Specialization Year in Cardiac and High-Risk Anesthesia. He moved to Penn after several years as a private practice anesthesiologist. The combination of experience, efficiency, and collaboration has led him and his team to develop and implement measures designed to improve patient flow as well as patient care. He is keenly interested in developing standards for patient care and resident education. Since joining Penn, Dr Weiss has written several papers and chapters. He has also been asked to edit several monographs, and is very proud of his current association with Current Opinion in Anesthesiology. Working with Dr Lee Fleisher, Dr Weiss has produced a textbook, Non-Operating Room Anesthesia. Dr Weiss was a founding member of the Society of Non-Operating Room Intervention and Anesthesia (SONORIA), in response to the astounding growth of Non-Operating Room Anesthesia (NORA) cases. SONORIA recently merged with the Association of Anesthesia Clinical Directors (AACD), where Dr Weiss sits on the Board of Directors. In addition to writing, Dr Weiss developed a NORA course for residents at the University of Pennsylvania, one of the first such courses in the United States. Shortly after, the Accreditation Council for Graduate Medical Education (ACGME) mandated the two week NORA rotation for all accredited residency programs. This broad mandate is vague as to what is to be taught. Different programs have different levels of ability or resources to expose residents to the full spectrum of the NORA setting. In order to standardize both anesthesia provider training as well as improve patient care, Dr Weiss, through Penn, has developed an online training program: NORAlink. NORAlink is designed to provide an integrated teaching platform across the spectrum of NORA, through a multi-modal approach. NORAlink has value not only to residency training programs, but can also be the standard teaching tool for the entire anesthesia provider team, including Staff Anesthesiologists, Certified Registered Nurse Anesthetists, and Procedural Physicians supervising the delivery of anesthesia in the NORA setting.

Socio-emotional competencies as predictors of performance of nursing students in simulated clinical practice.

Socio-emotional competencies positively influence academic performance and clinical practice of students enrolled in a Nursing degree. However, there is a lack of studies that relate these competencies with performance in a high-fidelity clinical simulation training scenario. To analyze the relationship between socio-emotional competencies and performance in simulated clinical practices of a sample of 4th-year Nursing degree students. Transversal descriptive study conducted in Spain. A sample of 91 students enrolled in their last academic year of the Nursing degree, who were undergoing clinical practices along with simulation sessions. Socio-emotional competencies (communication skills, coping with stress, self-efficacy, engagement, etc.) were analyzed through the use of self-administered questionnaires and their performance in high-fidelity clinical simulation sessions. The socio-emotional competencies had a positive and statistically-significant correlation (p < 0.05) with performance in simulated clinical practices. A relationship between socio-emotional competencies and performance in simulated practices was observed [R2 = 0.502; F (20.55) = 2.827; p = 0.01]. The socio-emotional competencies of 4th-year nursing students were associated to their performance in simulated clinical practices.

Multidisciplinary Difficult Airway Course: An Essential Educational Component of a Hospital-Wide Difficult Airway Response Program

A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scores and themes derived from qualitative assessments, and prepost course knowledge assessment MCQ scores. Tertiary care academic hospital center PARTICIPANTS: Students, residents, fellows, and practicing physicians from the departments of Surgery, Otolaryngology Head and Neck Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine; advanced practice providers (nurse practitioners and physician assistants), nurse anesthetists, nurses, and respiratory therapists. Totally, 23 MDACs have been conducted, including 499 participants. Course evaluations were uniformly positive with mean score of 86.9 of 95 points. Qualitative responses suggest major value from high-fidelity simulation, the hands-on skill stations, and teamwork practice. MCQ scores demonstrated significant improvement: median (interquartile range) pre: 69% (60%-81%) vs post: 81% (72%-89%), p < 0.001. Implementation of a MDAC successfully disseminated principles and protocols to all airway providers. Demonstrable improvement in prepost course knowledge assessment and overwhelmingly positive course evaluations (quantitative and qualitative) suggest a critical and ongoing role for the MDAC course.

Analysis of Pediatric Trauma in Combat Zone to Inform High-Fidelity Simulation Predeployment Training.

The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone. A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014. Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management. Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58). We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.

Simulation Training Facilitates Physical Therapists' Self-efficacy in the Intensive Care Unit

Purpose: Physical therapists (PTs) perform early mobilization in the intensive care unit (ICU), but specialized knowledge, skills, and behaviors for ICU clinical practice pose unique challenges. High-fidelity human simulation (HFHS) training prepares medical professionals for ICU practice, but evidence on HFHS training for PTs is limited. The purpose was to develop and evaluate an HFHS-based training program focused on improving PTs' self-efficacy for ICU clinical practice. Methods: Six PTs participated in 3 immersive HFHS experiences, each including a simulation and group debriefing. All participants completed self-efficacy surveys pre- and posttraining. A focus group was conducted to gather participant perspectives on the learning experience. Results: Significant improvements in 3 self-efficacy categories occurred: performing a chart review, understanding precautions/medications, and implementing early mobilization. Qualitative analysis of the focus group revealed 4 themes: simulation facilitates positive reinforcement and confidence building; collaborative learning in a safe environment promotes skill acquisition, teamwork in training improves clinical collaboration; and simulation provides effective orientation to complex line management. The small sample size and unknown psychometric properties of the self-efficacy scale limit these results. Conclusions: The HFHS program facilitated PTs' teamwork, collaboration, and self-efficacy for ICU clinical practice. Further investigation is recommended to evaluate the efficacy of HFHS as a training tool to enhance PT practice in the ICU.

High-Fidelity Realistic Acute Medical Simulation and SBAR Training at a Tertiary Hospital in Blantyre, Malawi.

High-Fidelity Realistic Acute Medical Simulation and SBAR Training at a Tertiary Hospital in Blantyre, Malawi.

Student Registered Nurse Anesthetists: The Impact of Structured High Fidelity Simulation on Anesthesia Ready Time

Introduction: Student registered nurse anesthetists (SRNAs) at a large academic medical center are limited in clinical training experiences owing to the subjective perception by local anesthesia department administrators of decreased oper-ating room efficiency with SRNA involvement. The purpose of this project was to utilize structured high-fidelity simula-tion (HFS) to increase basic skill proficiency in SRNAs and evaluate the impact of the simulation within the first month of clinical training.Methods: Utilizing the Iowa Model of Evidence-Based Practice to Promote Quality Care, a 5-week structured HFS program was inserted into the nurse anesthesia curriculum before the SRNAs’ first clinical rotation. The program pro-moted basic anesthesia skill proficiency through the assimilation of previously taught and tested technical skills. In-room times and anesthesia ready times of all SRNA cases involving general anesthesia with the placement of an endotrache-al tube during September 2012 and 2013 were compiled by use of retrospective chart review. Using the calculation of elapsed time between in-room time and anesthesia ready time (IRTART), the clinical performance of 2 consecutive classes of SRNAs was compared, one with structured HFS training and one without.Results: The mean IRTART for both groups was similar at 20 minutes with a standard deviation of 10 minutes. The IRTARTs from both groups were within the institution’s operative norm.Conclusion: Structured HFS did not impact the anesthesia ready time of new-to-practice SRNAs. However, the in-formation collected during implementation of HFS and data analysis can be used to develop future avenues to improve current processes for structured HFS and clinical training opportunities.

Effect of In Situ High-Fidelity Simulation Training on the Emergency management of Pneumonia (INSTEP): a mixed-methods study.

The patient safety agenda has propelled the rise of simulation education, but relatively few evaluations of simulation-based educational interventions have focused on patient outcomes. To evaluate the impact of an in situ, high-fidelity simulation teaching intervention on the management of community-acquired pneumonia in the ambulatory care unit of a district general hospital. This study used a mixed-methods approach to evaluate the impact of a programme of 10 in situ high-fidelity simulation education sessions delivered to a total of 10 junior doctors, nine nurses and seven healthcare assistants. Participants were tasked with managing a manikin simulating a patient with pneumonia in real time in a working clinical area. Subsequent structured debrief emphasised key themes from the national guidelines on pneumonia management. The intervention was evaluated through an immediate feedback form, follow-up semistructured interviews by independent qualitative researchers that underwent content analysis and triangulation with audit data on compliance with national pneumonia guidelines before and after the simulation intervention. The in situ simulation intervention was valued by participants both in immediate written feedback and in follow-up semistructured interviews. In these interviews, 17 of 18 participants were able to identify a self-reported change in practice following the simulation intervention. Furthermore, most participants reported observing a change in the clinical practice of their colleagues following the training. Collected audit data did not show a statistically significant change in compliance with the guidelines for the management of pneumonia. This study found evidence of a change in both self-reported and observed clinical practice following a simulation intervention, supporting expert opinion that simulation education can impact clinician behaviours and patient outcomes in complex clinical scenarios. Furthermore, this feasibility study provides a transferrable method to evaluate the real-world impact of simulation education that merits further investigation through an appropriately powered study.

High fidelity simulation to improve multidisciplinary team working with pre-registrants.

Simulation has been introduced in recent years into international nursing curricula. Many educational establishments have developed simulation centres that resemble the ward settings nursing students will be exposed to so that they can use the same equipment as they will in clinical practice. This is referred to as high fidelity simulation training (HFST). This article reflects on an example of a multidisciplinary HFST scenario in the context of the assessment and accountability and learning domains of the Nursing and Midwifery Council standards. The article also discusses the assessment, feedback and evaluation process.

Teaching childbirth with high-fidelity simulation. Is it better observing the scenario during the briefing session?

The design of optimal courses for obstetric undergraduate teaching is a relevant question. This study evaluates two different designs of simulator-based learning activity on childbirth with regard to respect to the patient, obstetric manoeuvres, interpretation of cardiotocography tracings (CTG) and infection prevention. This randomised experimental study which differs in the content of their briefing sessions consisted of two groups of undergraduate students, who performed two simulator-based learning activities on childbirth. The first briefing session included the observations of a properly performed scenario according to Spanish clinical practice guidelines on care in normal childbirth by the teachers whereas the second group did not include the observations of a properly performed scenario, and the students observed it only after the simulation process. The group that observed a properly performed scenario after the simulation obtained worse grades during the simulation, but better grades during the debriefing and evaluation. Simulator use in childbirth may be more fruitful when the medical students observe correct performance at the completion of the scenario compared to that at the start of the scenario.Impact statementWhat is already known on this subject? There is a scarcity of literature about the design of optimal high-fidelity simulation training in childbirth. It is known that preparing simulator-based learning activities is a complex process. Simulator-based learning includes the following steps: briefing, simulation, debriefing and evaluation. The most important part of high-fidelity simulations is the debriefing. A good briefing and simulation are of high relevance in order to have a fruitful debriefing session.What do the results of this study add? Our study describes a full simulator-based learning activity on childbirth that can be reproduced in similar facilities. The findings of this study add that high-fidelity simulation training in childbirth is favoured by a short briefing session and an abrupt start to the scenario, rather than a long briefing session that includes direct instruction in the scenario.What are the implications of these findings for clinical practice and/or further research? The findings of this study reveal what to include in the briefing of simulator-based learning activities on childbirth. These findings have implications in medical teaching and in medical practice.

Exploring the use of high-fidelity simulation training to enhance clinical skills

The use of interprofessional simulation training to enhance nursing students' performance of technical and non-technical clinical skills is becoming increasingly common. Simulation training can involve the use of role play, virtual reality or patient simulator manikins to replicate clinical scenarios and assess the nursing student's ability to, for example, undertake clinical observations or work as part of a team. Simulation training enables nursing students to practise clinical skills in a safe environment. Effective simulation training requires extensive preparation, and debriefing is necessary following a simulated training session to review any positive or negative aspects of the learning experience. This article discusses a high-fidelity simulated training session that was used to assess a group of third-year nursing students and foundation level 1 medical students. This involved the use of a patient simulator manikin in a scenario that required the collaborative management of a deteriorating patient.

The New RN and Emergency Patient Care Scenarios: How Simulation Can Help

Failure to rescue a patient that is experiencing deteriorating symptoms is a major cause of mortality in the acute care settings. The nurse is at the fore-front of prevention and recognition of patient distress. Failure to rescue patients that are displaying symptoms of deterioration is becoming a national crisis due to treatment complications and missed signs and symptoms of impending arrest [1]. New nurse graduates must have additional training to assist them in the recognition of the signs of impending crisis. This paper will discuss the need for additional training after nursing school to address this issue and assist the new graduate nurse in their transition to practice. The development of a New Graduate Nurse simulation education program for Littleton Regional Healthcare and their Alliance Hospitals was the primary focus of this project. PICOT: How will the use of simulated emergency scenarios with intermittent audit/feedback impact the knowledge level and clinical reasoning of new nurse graduates in an acute care setting? High Fidelity Simulation patient scenarios of impending crisis were developed for a 4-hour educational workshop. New nurse graduates with under 2.5 years experience attended the training with results showing that high fidelity simulation training scenarios with intermittent audit feedback assisted the new nurses to recognize signs and symptoms of impending crisis, how to develop skills to work as a team member, and gave them more confidence in reporting mistakes and voicing concerns. The literature search completed for this study shows that the new graduate nurse needs to develop clinical reasoning skills and gain experience on how to respond to patients with clinical emergencies and simulation can assist with this knowledge to practice gap [2].

A Quality Improvement Project Using High-Fidelity Simulation Training to Improve Clinical Knowledge among Critical Care Transport Nurses

BackgroundTo cultivate clinical expertise, many critical care transport (CCT) programs have engaged simulation as a means of providing ongoing clinical education for crewmembers. MethodA pretest, posttest, repeated-measures design was used to evaluate whether CCT nurses' clinical knowledge improved immediately after and three months after high-fidelity simulation training. ResultsThe increase in mean test scores from preintervention to postintervention was not statistically significant, and knowledge was not sustained after three months. ConclusionsIntroducing pre- and postsimulation evaluations into staff training activities provided a reference point for CCT nurses to benchmark their individual progress and allowed department education leaders to gauge the effectiveness of their training interventions.

An Emergency Simulation Course in a Postdoctoral General Dentistry Program: The New York Presbyterian/Weill Cornell Medicine Experience.

Dentists can encounter life-threatening medical emergencies during the provision of routine dental care and must therefore be comfortable with the management of these emergencies. High-fidelity simulation has been used routinely in medical and surgical training and is a recognized and effective educational and assessment tool. The aim of this study was to develop and evaluate a new high-fidelity simulation training course in medical emergency management for residents in the General Practice Residency program at New York Presbyterian/Weill Cornell Medicine. In academic years 2014-16, first-year GPR residents were required to take a simulation course covering medical emergency scenarios that are commonly encountered in the dental office. The course involved a team approach to emergency management with active participation by faculty and residents and with each training session followed by feedback and a formal review of the emergencies covered. Evaluation was achieved through completion of questionnaires by the residents following each session. A total of 14 residents (seven in each year) participated, completing 78 questionnaires in the two-year period. They gave the course an overall rating of 4.91 on a scale from 1 to 5, indicating strong agreement with the utility of the course as a learning tool in medical emergency management training. This course is now fully integrated into the GPR educational program at this institution and is a successful component of the emergency medicine curriculum.

Shoulder Dystocia Delivery by Emergency Medicine Residents: A High-fidelity versus a Novel Low-fidelity Simulation Model-A Pilot Study.

Shoulder dystocia (SD) requires emergent intervention to prevent maternal and fetal harm, and simulation models for training can be expensive. We developed a novel, cheap and easily transportable low-fidelity simulation (LFS) model to compare to a commercially available high-fidelity simulation (HFS) model. Emergency medicine residents were randomized to training on the HFS or novel LFS model. Subjects completed a pretest and a 1-week and 6-month posttest including a self-assessment and a simulated SD delivery. Twenty-seven of the 43 residents completed the study (63%). The number of individuals performing dangerous maneuvers at baseline was similar, 1week after training was five in HFS and 11 in LFS (p=0.08) groups and at 6 months was again similar between groups. Mean checklist scores for appropriate actions increased 1 week after training but returned to baseline by 6 months and were similar between groups. The rate of successful delivery, median time to successful delivery, and maximum force applied improved at 1 week and was sustained at 6 months in both groups. Within our limited study population, we did not find a large difference in the occurrence of dangerous actions during simulated SD delivery following HFS and LFS training. Our novel and easily transportable LFS trainer, assembled for less than US$10 each, may be a useful tool to train inexperienced providers on the steps of this procedure. However, this requires further study, as does whether HFS models with force monitoring capabilities may be helpful to train providers to minimize dangerous maneuvers such as the application of excessive force.

Hospital to Home: A Quality Improvement Initiative to Implement High-fidelity Simulation Training for Caregivers of Children Requiring Long-term Mechanical Ventilation

BackgroundPreparing families of children requiring long-term mechanical ventilation (LTMV) to manage medical emergencies at home is challenging. Opportunities for family caregivers to rehearse crisis management in a controlled setting before discharge are limited. ObjectiveWe aimed to create a multimodal discharge preparedness curriculum, incorporating high-fidelity simulation training, to prepare family caregivers of children with complex medical conditions requiring long-term mechanical ventilation. We sought to determine which curricular elements were most helpful and whether this curriculum impacted the rate of readmissions within 7 days of hospital discharge. MethodsThe curriculum included instructional videos, printed handouts, cardiopulmonary resuscitation training, and two mandatory high fidelity simulation scenarios depicting tracheostomy- and ventilator-related emergencies. Teams of one to three family caregivers per patient managed each scenario. A video-based debriefing focused on identifying and closing performance gaps. Participants rated their perceptions regarding each curricular element and its relative impact on their preparedness for discharge. Results87 family caregivers completed the curriculum. Simulation-enhanced curriculum was well-received by participants. Participants reported that post-simulation debriefing was the most beneficial component. We observed a trend toward reduced readmissions within 7 days of discharge since implementation of our revised curriculum. ConclusionSimulation training can be incorporated into discharge training for families of children requiring LTMV. Rehearsal of emergency management in a simulated clinical setting increases caregiver confidence to assume care for their ventilator-dependent child.

High Fidelity Simulation and Safety Training for Transport Teams for Potential Accidents/Incidents

High Fidelity Simulation and Safety Training for Transport Teams for Potential Accidents/Incidents

Trauma Anesthesiology as Part of the Core Anesthesiology Residency Program Training: Expert Opinion of the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness (ASA COTEP).

Trauma Anesthesiology as Part of the Core Anesthesiology Residency Program Training: Expert Opinion of the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness (ASA COTEP).