Medium-fidelity Simulation Research Articles

Value of real life (in situ) simulation training for tracheal intubation skills in medical undergraduates during short duration anesthesia rotation.

Background and Aims:Skill of a successful endotracheal intubation needs to be acquired by training and attaining several competencies simultaneously. It becomes more challenging when we have to deliver the key concepts in a limited period of time. The medium fidelity simulator is a valuable tool of training for such scenarios. For this purpose we aim to compare the efficacy of structured training in endotracheal intubation between real life simulation and the conventional teaching method.Materials and Methods:The year 4 medical students had their attachment in anaesthesia for a period of 6 months from Jun — Dec 2009 were randomly divided into Group (Gp) A who had conventional teaching and Group B who were taught by four simulated sessions of endotracheal intubation. Performance of both the groups was observed by a person blinded to the study against a checklist on a 7 point rating scale in anaesthetized patient.Results:Total 57 students, 29 in Gp A and 28 in Gp B were rotated in the anaesthesia during the study period. Evaluation of the individual component tasks revealed that simulated group achieved a significant difference in the scoring for laryngoscope and intubation technique. (P = 0.026, 0.012) The comparison of overall competence again showed that the 64.3% of student in Gp B achieved an excellent score in comparison to Gp A in which only 41.4% achieved excellent. (P = 0.049). Similarly the lesser number of students in Gp B (14.3%) require remediation as compared to the Gp A, in which the requirement was 40% (P=0.04).Conclusion:We conclude that all essential skills components of tracheal intubation in correct flow and sequence are acquired more efficiently by real life simulated training.

Controller Use of a Block Occupancy-Based Surface Surveillance Display for Surface Management

Advanced surface surveillance capabilities cannot be economically justified at small and medium airports, though these airports continue to suffer from runway incursions. A block occupancy-based surface surveillance approach, in which runways and taxiways are divided into blocks and the occupancy of a block is displayed to the controller, may provide a low cost solution to these airports. A medium fidelity simulation was conducted to examine controller situation awareness, workload, and aircraft identification performance with the use of the block occupancy display. Results indicate that the presence of the display improves controller detection of safety critical runway events. However, controllers indicate that associating occupied blocks with aircraft identification is burdensome.

Training nurses in trauma management

Since major trauma networks were introduced, medical and non-medical staff have been required to undergo trauma training. The recommended training programme is the advanced trauma life support course, but its cost and the difficulties involved in securing study leave can make it unfeasible as a training option. This article discusses the trauma intermediate life support programme, an innovative, one-day programme for staff to acquire knowledge and skills in trauma management. The programme, which focuses on damage-control resuscitation, involves low- and medium-fidelity simulation in trauma or resuscitation rooms. It has been quantitatively reviewed by 50 candidates, who all stated that it has helped them to improve their practice.

Evaluation of operating department practitioners’/circulation nurses’ role in managing a can’t intubate can’t ventilate scenario using cannula cricothyroidotomy

Evaluation of operating department practitioners’/circulation nurses’ role in managing a can’t intubate can’t ventilate scenario using cannula cricothyroidotomy

Predicting self-reported violations among novice license drivers using pre-license simulator measures

Novice drivers are overrepresented in crash statistics and there is a clear need for remedial measures. Driving simulators allow for controlled and objective measurement of behavior and might therefore be a useful tool for predicting whether someone will commit deviant driving behaviors on the roads. However, little is currently known about the relationship between driving-simulator behavior and on-road driving behavior in novice drivers. In this study, 321 drivers, who on average 3.4 years earlier had completed a pre-license driver-training program in a medium-fidelity simulator, responded to a questionnaire about their on-road driving. Zero-order correlations showed that violations and speed in the simulator were predictive of self-reported on-road violations. This relationship persisted after controlling for age, gender, mileage, and education level. Respondents with a higher number of violations, faster speed, and lower number of errors in the simulator reported completing fewer hours of on-road lessons before their first on-road driving test. The results add to the literature on the predictive validity of driving simulators, and can be used to identify at-risk drivers early in a driver-training program.

Student Perception of High Fidelity Medical Simulation for an International Trauma Life Support Course

High fidelity medical simulators (HFMS) are accepted tools for health care instruction. The use of HFMS was incorporated into an International Trauma Life Support course, and course participants were surveyed regarding attitudes toward HFMS. Course participants, including physicians, nurses, and prehospital personnel, were given pre- and post-course questionnaires measuring their confidence in knowledge and treatment of trauma resuscitation, as well as their attitudes towards the utility and realism of immersive simulation. The participants were randomly assigned to take a course examination either before or after their simulator session. Thirteen course participants of varying backgrounds and degrees of clinical experience were surveyed and tested. All surveyed areas improved following simulator training, including comfort level with simulation as a training method (17%), perception of the realism of HFMS (15%), and reported self-confidence in knowledge, experience and training in trauma care (27%). Test scores were improved in the post-simulation group as opposed to the pre-simulation group (86% pass rate in the post-simulation test group versus 50% pass rate in the pre-simulation test group). High fidelity medical simulation was accepted by medical professionals of different backgrounds and experience. Attitudes towards simulation and self-confidence improved after simulator sessions, as did test scores, suggesting improved comprehension and retention of course materials. Further testing is required to validate the findings of this small, observational study.

Automaticity and Expressive Behavior in Virtual Actors: Notes on the Organization of Mammalian Behavior Systems

Much of the most expressive behavior in humans - expressions of shock or alarm, gaze aversion, or explosive rage - are the result of automatic processes that engage before deliberative processing can respond. In some cases, such as weeping, the deliberative system may have only limited ability to override the automatic system. These processes are implemented by a network of phylogenetically old, special purpose, somewhat redundant systems that give rise to the particular idiosyncratic behavior we associate with automatic reactions to emotional events. In this paper, I'll review some of the ethological and neuropsychological results on low-level systems related to threat response, and their relation to the simulation of virtual characters. I will also discuss work in progress on building a medium-fidelity simulation of these systems.

Examining the impact of high and medium fidelity simulation experiences on nursing students’ knowledge acquisition

Aim This paper describes a study that measured and compared knowledge acquisition in nursing students exposed to medium or high fidelity human patient simulation manikins. Background In Australia and internationally the use of simulated learning environments has escalated. Simulation requires a significant investment of time and money and in a period of economic rationalisation this investment must be justified. Assessment of knowledge acquisition with multiple choice questions is the most common approach used to determine the effectiveness of simulation experiences. Method This study was conducted in an Australian school of nursing; 84 third year nursing students participated. A quasi-experimental design was used to evaluate the effect of the level of manikin fidelity on knowledge acquisition. Data were collected at three points in time: prior to the simulation, immediately following and two weeks later. Results Differences in mean scores between the control (medium fidelity) and experimental (high fidelity) groups for Tests 1, 2 and 3 were calculated using independent t tests and were not statistically significant. Analysis of covariance (ANCOVA) was conducted to determine whether changes in knowledge scores occurred over time and, while an improvement in scores was observed, it was not statistically significant. Conclusion The results of this study raise questions about the value of investing in expensive simulation modalities when the increased costs associated with high fidelity manikins may not be justified by a concomitant increase learning outcomes. This study also suggests that multiple choice questions may not be the most appropriate measure of simulation effectiveness.

Combining cognitive and visual distraction: Less than the sum of its parts

Driver distraction has become a leading cause of motor-vehicle crashes. Although visual and cognitive distraction has been studied extensively, relatively little research has addressed their combined effects on drivers’ behavior. To fill this gap, a medium-fidelity simulator study examined the driver behavior before, during and after three types of distraction. Driving without distraction was compared to visual distraction, cognitive distraction, and combined visual and cognitive distraction. The results show that the visual and combined distraction both impaired vehicle control and hazard detection and resulted in frequent, long off-road glances. The combined distraction was less detrimental than visual distraction alone. Cognitive distraction made steering less smooth, but improved lane maintenance. All distractions caused gaze concentration and slow saccades when drivers looked at the roadway, and cognitive and combined distraction increased blink frequency. Steering neglect, under-compensation, and over-compensation were three typical steering failures that were differentially associated with the different distractions: steering neglect and over-compensation with visual distraction and under-compensation with cognitive distraction. Overall, visual distraction interferes with driving performance more than cognitive distraction, and visual distraction dominates the performance decrements during combined distraction. These results suggest that minimizing visual demand is particularly important in the design of in-vehicle systems and in the development of distraction countermeasures.

The validity of driving simulation for assessing differences between in-vehicle informational interfaces: A comparison with field testing

Data from on-road and simulation studies were compared to assess the validity of measures generated in the simulator. In the on-road study, driver interaction with three manual address entry methods (keypad, touch screen and rotational controller) was assessed in an instrumented vehicle to evaluate relative usability and safety implications. A separate group of participants drove a similar protocol in a medium fidelity, fixed-base driving simulator to assess the extent to which simulator measures mirrored those obtained in the field. Visual attention and task measures mapped very closely between the two environments. In general, however, driving performance measures did not differentiate among devices at the level of demand employed in this study. The findings obtained for visual attention and task engagement suggest that medium fidelity simulation provides a safe and effective means to evaluate the effects of in-vehicle information systems (IVIS) designs on these categories of driver behaviour. Statement of Relevance: Realistic evaluation of the user interface of IVIS has significant implications for both user acceptance and safety. This study addresses the validity of driving simulation for accurately modelling differences between interface methodologies by comparing results from the field with those from a medium fidelity, fixed-base simulator.

Simulation‐based learning in nurse education: systematic review

This paper is a report of a review of the quantitative evidence for medium to high fidelity simulation using manikins in nursing, in comparison to other educational strategies. Human simulation is an educational process that can replicate clinical practices in a safe environment. Although endorsed in nursing curricula, its effectiveness is largely unknown. A systematic review of quantitative studies published between 1999 and January 2009 was undertaken using the following databases: CINAHL Plus, ERIC, Embase, Medline, SCOPUS, ProQuest and ProQuest Dissertation and Theses Database. The primary search terms were 'simulation' and 'human simulation'. Reference lists from relevant papers and the websites of relevant nursing organizations were also searched. The quality of the included studies was appraised using the Critical Appraisal Skills Programme criteria. Twelve studies were included in the review. These used experimental or quasi-experimental designs. All reported simulation as a valid teaching/learning strategy. Six of the studies showed additional gains in knowledge, critical thinking ability, satisfaction or confidence compared with a control group (range 7-11%). The validity and reliability of the studies varied due to differences in design and assessment methods. Medium and/or high fidelity simulation using manikins is an effective teaching and learning method when best practice guidelines are adhered to. Simulation may have some advantage over other teaching methods, depending on the context, topic and method. Further exploration is needed to determine the effect of team size on learning and to develop a universal method of outcome measurement.

Multiple-Model Adaptive Fault-Tolerant Control of a Planetary Lander

In this paper we present an approach to fault-tolerant control based on multiple models, switching, and tuning and its implementation to a hardware-in-the-loop simulation of Delta Clipper Experimental dynamics. The Delta Clipper Experimental is characterized by large control input redundancy, which made it an ideal test bed for evaluation of advanced fault-tolerant and adaptive reconfigurable control strategies. The overall failure detection, identification, and accommodation architecture is an upgraded version of our Fast Online Actuator Reconfiguration Enhancement (FLARE) system. The FLARE approach is based on representing different possible fault and failure scenarios using multiple observers, such that the case of nominal (no-failure) operation is covered along with the loss-of-effectiveness, lock-in-place, and hardover failures of the flight control effectors. Based on a suitably chosen performance criterion, the FLARE system quickly detects single or multiple failures and reconfigures the controls, thus achieving either the original desired performance or graceful performance degradation. In the first stage of the project, the FLARE system was tested on a medium-fidelity simulation of Delta Clipper Experimental dynamics, resulting in excellent performance over a large range of single and multiple faults and failures. Following that, in collaboration with Boeing Phantom Works, the FLARE run-time code was installed at their site and tested on a hardware-in-the-loop test bed consisting of an electromechanical actuator actuating a gimballed engine as a part of a simulation of the Delta Clipper Experimental dynamics. A large number of hardware-in-the-loop simulations were run to cover a dense test-case matrix, including cases of up to 10 simultaneous control effector failures. In all cases FLARE was able to quickly and accurately detect the failures and reconfigure the controls, resulting in excellent overall system performance. In this paper we describe the Delta Clipper Experimental and its dynamics model, along with the multiple models, switching, and tuning based modification of our FLARE system. This is followed by a description ofthe experimental test bed and a discussion of the results obtained through hardware-in-the-loop testing.

Unanticipated difficult airway management in anaesthetised patients: a prospective study of the effect of mannequin training on management strategies and skill retention

This prospective study on a medium-fidelity simulator (SimMan, Laerdal Medical Corporation, Wappingers Falls, NY, USA) examined the management of unanticipated difficult airway by 21 anaesthetists and the effect of training in this context. There were two scenarios investigated: 'cannot intubate, can ventilate' (CI) and 'cannot intubate, cannot ventilate' (CICV). Following initial evaluation, volunteers underwent training in the 'Difficult Airway Society' (DAS) algorithms and associated technical skills. At 6-8 weeks and 6-8 months, performance was compared with the initial evaluation. There was a more structured approach following training (p < 0.05), which was sustained at 6-8 months, but only for the CICV scenario (p < 0.01). In CI, use of standard and intubating laryngeal mask airway increased following training (p = 0.021). This was sustained over time (p = 0.01). In both scenarios there was a reduced incidence of equipment misuse (p < 0.0005), which was sustained over time (p < 0.0001). We conclude that simulation-based training significantly improves performance for at least 6-8 weeks. Training should be repeated at intervals of 6 months or less.

How to Create a Clinical Data Station for Use in a High Fidelity Medical Simulation Lab

Many advances have been made in the capabilities of high-fidelity medical simulators such that they have become increasingly more life-like. To create a more life-like experience, it is important to incorporate into the simulation environment as many features found in the real life setting as possible. One of these features is the delivery of diagnostic information. We have assembled a very cost-effective data station that allows for the real-time delivery of laboratory values, electrocardiograms, and radiologic studies in a manner which is most similar to that which exists in real Emergency Departments. This data station allows for a more realistic simulated patient encounter. It helps participants hone skills involved in radiographic interpretation using an interface found in the hospital. It also facilitates smooth flow of events by streamlining the delivery of laboratory and electrocardiographic data. Utilizing this data station has allowed us to increase the efficiency of our scenarios, improve participant satisfaction, and offer some additional practice at interpreting data as it would be viewed in the hospital.

Comparison of cricothyroidotomy on manikin vs. simulator: a randomised cross‐over study*

We compared the time taken to perform cricothyroidotomy on a manikin to that on a medium fidelity simulator, to assess the effect of psychological stress and time pressure on performance. Seventy anaesthetists participated in this randomised cross-over study. Fifty-four (77%) anaesthetists took longer on the simulator, with the mean (SD) time taken to perform the procedure on the manikin and simulator 34 (18) and 48 (11) s, respectively (p < 0.001). Anaesthetists with more experience performed the procedure more quickly on both manikin and simulator. We conclude that psychological stress and time pressure in real-life scenarios can affect the performance of cricothyroidotomy.

Pediatric Simulation Based Didactics for the Delivery of Difficult News.

BACKGROUND: High fidelity medical simulation is an evolving tool, currently used by many institutions to teach procedural skills, teamwork skills and medical decision making skills. There are situations where skillful communication is essential when caring for patients and their families. Two examples are dealing with the death of a child and discussing a medical error with a family. A resident may never receive training or the opportunity to practice how to communicate in these types of situations, and their first experience might be in an actual case. METHOD: We created and pilot tested two scenarios to assist in teaching communication strategies for delivering difficult news. The first scenario was a 6 m/o female with sudden infant death syndrome(SIDS). The teaching goals of this case were 1)practicing pediatric asystole algorithm, 2)deciding when to end a resuscitation and 3)communicating the information of the death of a child to the family. The second scenario was a 16 y/o male in the ED for gastroenteritis who is unintentionally paralyzed with rocuronium. The teaching goals of this case were 1)managing the airway, 2)considering etiologies of apnea/paralysis and 3)communicating the information of an unintentional medication administration to the family. We had concerns that running a scenario with a dead infant and a staged medical error might not be well received by the participants. The ability to suspend disbelief and replicating the emotions of these types of cases were new challenges for our simulation staff. The 6 m/o SIDS case was run for the PGY-2 and PGY-3 pediatric residents, and the PEM fellows. The PEM fellows also managed the medication error scenario. RESULTS: Participant feedback from project sessions is summarized below. (N=44)TableCONCLUSIONS: Our exploratory questions and concerns about running scenarios with infant death and staged medical error were answered with the feedback from the participants. All trainees felt the simulation-enhanced didactics for delivery of difficult news were both realistic and useful for their training needs.

High fidelity medical simulation in the difficult environment of a helicopter: feasibility, self-efficacy and cost

BackgroundThis study assessed the feasibility, self-efficacy and cost of providing a high fidelity medical simulation experience in the difficult environment of an air ambulance helicopter.MethodsSeven of 12 EM residents in their first postgraduate year participated in an EMS flight simulation as the flight physician. The simulation used the Laerdal SimMan™ to present a cardiac and a trauma case in an EMS helicopter while running at flight idle. Before and after the simulation, subjects completed visual analog scales and a semi-structured interview to measure their self-efficacy, i.e. comfort with their ability to treat patients in the helicopter, and recognition of obstacles to care in the helicopter environment. After all 12 residents had completed their first non-simulated flight as the flight physician; they were surveyed about self-assessed comfort and perceived value of the simulation. Continuous data were compared between pre- and post-simulation using a paired samples t-test, and between residents participating in the simulation and those who did not using an independent samples t-test. Categorical data were compared using Fisher's exact test. Cost data for the simulation experience were estimated by the investigators.ResultsThe simulations functioned correctly 5 out of 7 times; suggesting some refinement is necessary. Cost data indicated a monetary cost of $440 and a time cost of 22 hours of skilled instructor time. The simulation and non-simulation groups were similar in their demographics and pre-hospital experiences. The simulation did not improve residents' self-assessed comfort prior to their first flight (p > 0.234), but did improve understanding of the obstacles to patient care in the helicopter (p = 0.029). Every resident undertaking the simulation agreed it was educational and it should be included in their training. Qualitative data suggested residents would benefit from high fidelity simulation in other environments, including ground transport and for running codes in hospital.ConclusionIt is feasible to provide a high fidelity medical simulation experience in the difficult environment of the air ambulance helicopter, although further experience is necessary to eliminate practical problems. Simulation improves recognition of the challenges present and provides an important opportunity for training in challenging environments. However, use of simulation technology is expensive both in terms of monetary outlay and of personnel involvement. The benefits of this technology must be weighed against the cost for each institution.

Simulation Based Intervention as an Effective Teaching Tool for Teamwork and Pediatric Airway Skills

High fidelity medical simulation is an evolving tool, currently used by many institutions to teach medical students, residents, and other medical personnel. However, there is limited data on its efficacy as an educational intervention. To evaluate high fidelity medical simulation as an educational intervention for teaching emergency pediatric management teamwork and airway skills, we performed a prospective, case control, observational study, using 16 PGY-2 pediatric residents. All subjects were PALS/APLS certified, and had no prior experience with medical simulation. Residents were given a brief intro to the sim center, and then managed 2 scenarios, during which their baseline airway and teamwork skills were assessed. The participants were divided into groups 1 and 2. Group 1 returned to the simulation center for a full-day, simulation enhanced session on pediatric airway management and teamwork skills. Two months later, groups 1 and 2 underwent reassessment of their performance. Following the second assessment, group 2 returned for the same educational intervention as group 1. Finally, both groups returned for a final assessment. During the assessment sessions, data were collected using the RIHMSC Global Competency Score (a Likert scale for subjective competency scoring), the Behaviorally Anchored Rating Scale (BARS), a previously validated teamwork metric (MedTeams™, Dynamic Research Corporation, Andover, MA), and critical action checklists specific for each scenario. Results from the Global Competency Scores (range 1–7) and the BARS scores (range 1–7) are displayed below in tables 1(p<0.05 for both RIHMCSGCS and BARS). The results for successful intubation attempts, appropriate RSI, cricoid pressure and ETCO2 during the 96 total scenarios are also recorded in Table 1(p0.05 for all critical actions).Table OneThe global competency scores show a statistically significant correlation between the intervention and performance. The BARS scores improved with each session, although the educational intervention did not correlate with the improved performance. Critical actions show a trend of improvement, but this trend was not statistically significant. Our data support simulation as an effective tool for teaching teamwork skills and improving global competency in an emergency pediatric setting. Conflict of Interest: Authors indicated they have nothing to disclose.

Medium-Fidelity Medical Simulators: Use in a Pre-Hospital,Operational, Military Environment

On Operation Telic 6, the UK Med Group consisting of 3 Close Support Medical Regiment and 205 Field Hospital (Volunteers) deployed to providemedical support to coalition forces in Iraq. Personnel...

Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?

To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum. Level 1 trauma center and academic emergency medicine training program. Emergency department (ED) staff including nurses, technicians, emergency medicine residents, and attending physicians. ED staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC) also received an 8 hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered. A comparison group, also ETCC trained, was assigned to work together in the ED for one 8 hour shift. Experimental and comparison teams were observed in the ED before and after the intervention. Single, crossover, prospective, blinded and controlled observational study. Teamwork ratings using previously validated behaviorally anchored rating scales (BARS) were completed by outside trained observers in the ED. Observers were blinded to the identification of the teams. There were no significant differences between experimental and comparison groups at baseline. The experimental team showed a trend towards improvement in the quality of team behavior (p = 0.07); the comparison group showed no change in team behavior during the two observation periods (p = 0.55). Members of the experimental team rated simulation based training as a useful educational method. High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training. This approach, using a number of patients, is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training. It is, however, unclear how much simulator based training must augment didactic teamwork training for clinically meaningful differences to become apparent.