Multiple Patient Scenarios Research Articles

The new Diploma of Rural Generalist Anaesthesia: Supporting Australian rural and remote communities.

In 2023, a Diploma of Rural Generalist Anaesthesia (DipRGA) was implemented across Australia. Developed collaboratively by the Australian and New Zealand College of Anaesthetists (ANZCA), the Australian College of Rural and Remote Medicine (ACRRM) and the Royal Australian College of General Practitioners (RACGP), the 12-month qualification is completed during or following ACRRM or RACGP Rural Generalist Fellowship training. Focused on the needs of rural and remote communities for elective and emergency surgery, maternity care, resuscitative care for medical illness or injury, and stabilisation for retrieval, the DipRGA supports rural generalist anaesthetists working within collaborative teams in geographically isolated settings. The goal is a graduate who can anaesthetise American Society of Anesthesiologists physical status class 1, 2 and stable 3 patients for elective surgery, provide obstetric anaesthesia and analgesia, anaesthetise paediatric patients and undertake advanced crisis care within their scope of practice. Crucially, they also recognise both limitations of their skills and local resources available when considering whether to provide care, defer, refer or transfer patients. DipRGA curriculum design commenced by adapting the ANZCA specialist training curriculum with consideration of the training approach of both the ACRRM and the RACGP, particularly the rural and remote context. Curriculum content is addressed in seven entrustable professional activities supported by workplace-based assessments and multisource feedback. Trainees are supervised by rural generalist anaesthetists and specialist anaesthetists, and complete flexible learning activities to accommodate geographical dispersion. Standardised summative assessments include an early test of knowledge and an examination, adapted from the ACRRM structured assessment using multiple patient scenarios.

Designing learning simulations for cognitive absorption

‘The future of learning is immersive. In the future, learning will take the shape of a story, a play, a game; involving multiple platforms and players; driven by dialogue and augmented with technology, an interplay of immersive experiences, data, and highly social virtual worlds’ [1]. Our simulation was designed to raise aspirations as to what is ‘possible’ for our wider faculty as we expand our simulation-based education (SBE). The ‘Godzilla’ multi-casualty exercise offered a fun and engaging theme to the serious focus on student development and assessment. Facilitated at a music venue enabling creative visual and audio backdrops, to a dynamic and immersive learning space. This exploited sensory boundaries in the form of challenging environments, whilst focusing expectations for our student cohorts to demonstrate clinical praxis. The directing staff (DS) included academics, Critical Care Practitioners, Nurses, and Paramedics who ensured a multidisciplinary overview of students’ safety and feedback discussions, appraising decision making, treatment, and management of multiple patient scenarios. Drawing upon the multimedia and interdisciplinary expertise from the faculty, a holistic set of skills brought together the creation of an authentic educational experience, with the evaluation of the students against clinical expectations of a modern healthcare response. The main points of contact were at ‘handover’ post patient extraction and assessment, to senior clinicians. This exercise modelled inclusive approaches, reflected in the seminal Delphi study that identified requirements and opportunities in Immersive Learning namely: Facilitating Authentic Learning Experiences and Developing the Capabilities of the Future Workforce [1]. This approach aligns with the NHS Simulation Strategy [2] but also with the psychological concept of flow and deep absorption in learning proposed by the Open University Innovating Pedagogy report [3]. Premised on the innovation of best learning moments, our student tasks were designed to engender deep involvement through memorable learning activities. 36 level 4 Paramedic students and 24 level 6 Paramedic students undertook the simulated challenges. Facilitators and learners reported high levels of satisfaction and attainment of praxis. Comparisons were recognised between cohorts that informed future adaptations and design, evaluating tasks for future ambitions, fusing interdisciplinary endeavours. This successful exercise met the key learning objectives and students identified this as a ‘memorable’ point in their learning. Inclusion of our allied health professions had handover scenarios filmed with 360° and conventional cameras, and videos were edited for future curricular inclusion. The learning from this inaugural event will inform the diversity and complexity of future tasks set for students. Further feedback capture methods will be used to quantify further investment into future simulation-based educational endeavours. 1. Lee MJ, Georgieva M, Alexander B, Craig E, Richter J. State of XR & Immersive Learning Outlook Report 2021. Immersive Learning Research Network, Walnut, CA. 2021. 2. Health Education England (HEE) A national vision for the role of simulation and immersive technologies in health and care. NHS: 2020 3. Kukulska-Hulme A, Bossu C, Coughlan T, Ferguson R, FitzGerald E, Gaved M, Herodotou C, Rienties B, Sargent J, Scanlon E, Tang J, Wang Q, Whitelock D, Zhang S. Innovating Pedagogy 2021: Open University. Innovation Report 9: 2021

Twelve tips for OSCE-style Tele-assessment.

This article was migrated. The article was marked as recommended. The Australian College of Rural and Remote Medicine (ACRRM) has developed a flexible 'tele-assessment' approach to the delivery of its assessment modalities. Candidates can sit their examination remotely, close to their place of practice, which reduces the need for rural doctors - both candidates and examiners - to leave their communities for the purpose of assessment. A major component of the assessment process is the Structured Assessment using Multiple Patient Scenarios (StAMPS) examination, which blends the formats of an Objective Structured Clinical Examination (OSCE) and a traditional viva vocè examination. It is a high-stakes assessment, that was designed to be academically rigorous, flexible, valid, reliable, and fair. Since 2008 ACRRM has provided a videoconferencing option to candidates for their StAMPS examination allowing them to remain in or near their home location, while the examiners meet a central location. Travel restrictions due to the SARS-CoV-2 pandemic meant for the first time both candidates AND examiners participated in StAMPS via videoconference. ACRRM conducted an online StAMPS assessment using videoconferencing technology for 65 candidates in mid-May 2020, with all candidates, examiners and support staff remaining in or near their home communities. These Twelve Tips outline some of the experience gained in providing tele-assessment over the past twelve years.

Fellowship of the Australian College of Rural & Remote Medicine (FACRRM) Assessment: a review of the first 12 years

This article was migrated. The article was marked as recommended. This paper provides an overview of the first 12 years of the formal assessment program of the Australian College of Rural and Remote Medicine (ACRRM). The ACRRM Fellowship represents the world's first and only Fellowship exam in Rural Medicine.The ACRRM assessment program is mapped to its Rural Generalist curriculum, based on the principles of programmatic assessment. ACRRM offers candidates the opportunity to participate in assessment in or close to their home location. The ACRRM Rural Generalist Curriculum defines the scope and standards for independent general practice anywhere in Australia, with a focus on rural and remote settings.The program was initially developed in 2006 and has evolved during delivery from 2008 onwards, utilising the following modalities: Multi Source Feedback (MSF)Multiple Choice Questions (MCQ)Mini Clinical Evaluation Exercise (Mini-CEX)Case Based Discussion (CBD)Procedural Skills LogbookStructured Assessment using Multiple Patient Scenarios (StAMPS) StAMPS is a unique examination, blending the formats of an Objective Structured Clinical Examination and a traditional viva vocè.The program has an emphasis on formative assessment. Over the past 12 years there has been considerable work in developing resources for candidates, governance structures and quality assurance processes.ACRRM's Fellowship requirements represent a customised bespoke assessment tailored to ACRRM's curriculum and the Australian rural and remote context. ACRRM's assessment program has grown substantially with 649 Fellowships being awarded from 2008 - 2019, with considerable experience gained in rural and remote assessment. It now represents a mature firmly-established process as a vocational endpoint in Rural and Remote Medicine.ACRRM has continued to offer its 'tele-assessment' program throughout the COVID-19 pandemic, with candidates and examiners participating in assessment by use of distance technology while remaining in or near their home community. This model may provide some insights for other medical Colleges and educational institutions facing challenges in the current environment.

Treatment of epilepsy in adults: Expert opinion in South Korea

ObjectiveThe aim of this study was to gather the expert opinions of Korean epileptologists regarding the treatment of adult patients with epilepsy. MethodsA total of 42 neurologists who specialized in epilepsy were surveyed. They completed an online questionnaire describing multiple patient scenarios. Using these scenarios, they evaluated treatment strategies and gave their preference for specific antiepileptic drugs (AEDs) used to treat genetically mediated generalized epilepsy and focal epilepsy. ResultsInitial AED monotherapy, followed by a second form of alternative monotherapy or an add-on combination therapy, was the preferred treatment strategy. The experts reached consensus for 87.2% of the items. The most commonly selected AEDs for the initial monotherapy for patients with generalized epilepsy were levetiracetam or valproate. For those with focal epilepsy, levetiracetam, oxcarbazepine, or lamotrigine were the most popular selections. Ethosuximide was the treatment of choice only for patients with generalized epilepsy with prominent absence seizures. Levetiracetam was preferred as an add-on therapy for both generalized and focal epilepsy. For special populations of patients, such as elderly adults or those with comorbid diseases, levetiracetam or lamotrigine was selected as the treatment of choice. ConclusionMost of the survey results were in accordance with the US expert opinion survey published in 2016. This survey can assist clinicians in making clinical decisions when treating individual adult patients with epilepsy.

Utilizing Telepresence Robots for Multiple Patient Scenarios in an Online Nurse Practitioner Program.

Simulation has been utilized widely in nurse practitioner programs for competency development and training. With the growing number of online educational programs, innovative solutions need to be developed to assess student competency for a variety of clinical situations and scenarios. An innovative method is the implementation of telepresence robots for multiple patient scenarios in a simulated environment. This article demonstrates the use of multiple patient scenarios using telepresence robots in an online post master's acute care pediatric nurse practitioner program.

Changes in Expert Recommendations and Global Practice Patterns from 2012-2015: Results from an Annually Updated Online Decision Aid for Multiple Myeloma (MM)

BackgroundClinical practice guidelines for MM list many alternative therapeutic options with an equivalent category of evidence but lack recommendations on the best approaches for individual patient cases. To provide clinicians with expert guidance on treatment options for defined patient scenarios, we developed and updated an interactive, online decision aid that allows users to enter specific disease and patient characteristics, enter their planned treatment, and then compare their choice of therapy with those of an MM expert panel for that scenario. Here we report data from the most recent version (2015) of this tool, capturing changes in expert recommendations and treatment trends for MM over time and evaluating the impact of this online tool on clinical care.MethodsEach of 3 annual updates to the tool were developed with input from a panel of 5 MM experts. The individual experts provided treatment recommendations for multiple patient scenarios across the settings of induction therapy, maintenance therapy, and therapy for relapsed/refractory MM. A series of pull-down menus allowed users to select individual patient and disease characteristics identified by experts as important to consider when making treatment choices. These characteristics included: eligibility for autologous stem cell transplantation (for induction therapy only), results of chromosome analysis (cytogenetics/FISH), ECOG performance status, risk of renal insufficiency or peripheral neuropathy, previous therapy and depth of response (for maintenance and relapsed/refractory settings), and cardiac or pulmonary dysfunction (for relapsed/refractory setting). Users were then asked to state their intended management approach for that particular patient scenario. Once completed, recommendations for that scenario from each of the experts were displayed, and users were asked to indicate the impact of the expert recommendations on their treatment choice.ResultsExpert recommendations spanning the continuum of care were compiled in October 2012, November 2013, and March 2015 for the 3 different MM tool updates. As for earlier versions of the MM tool, each of the experts in the 2015 update provided recommendations for 32 case scenarios for induction therapy, for a total of 160 possible induction recommendations. Comparing overall induction therapy recommendations the use of bortezomib/lenalidomide/dexamethasone was approximately 40% in both 2013 and 2015, whereas the use of carfilzomib-containing regimens increased from 5% to 17%. None of the experts chose regimens with melphalan as induction therapy in 2015. In the relapsed/refractory setting, the use of newer therapeutic approaches continued to grow especially in the setting of patients who did not respond to induction therapy or relapsed within 6 months. For example, in those with prior proteasome inhibitor (PI) therapy, the selection of carfilzomib/lenalidomide/dexamethasone by experts rose from 11% to 38% from 2013 to 2015 with pomalidomide and lenalidomide selected for 20% to 25% of cases in the most recent tool. For prior IMiD and PI, the experts selected a new combination of pomalidomide with a PI (either bortezomib or carfilzomib) and dexamethasone in 55% of the case scenarios in 2015.To date, 170 different clinicians sought guidance on more than 259 patient case scenarios using the 2015 decision support tool. In the subset of cases (n = 104) in which users reported how the tool affected their management of patients with MM, 68% indicated the expert recommendations either confirmed or changed their intended treatment (22% changed; 46% confirmed), whereas 17% indicated that there would be barriers to implementing the expert recommendations, and 5% said they disagreed with the experts' recommendations.ConclusionsExpert opinions regarding optimal MM therapy continue to evolve with new evidence. Our data show that interactive online therapy decision aids that provide expert recommendations to clinicians for specific case scenarios can aid decision making and capture practice trends in this rapidly evolving environment. Preliminary data suggest that most clinicians using the online decision aid either confirmed or changed their treatment approaches for specific MM patient case scenarios based on expert recommendations. A detailed and updated analysis of expert and user data will be presented. DisclosuresKumar:Janssen: Consultancy, Research Funding; Novartis: Research Funding; Onyx: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Skyline: Consultancy, Honoraria; BMS: Consultancy; Sanofi: Consultancy, Research Funding. Lentzsch:BMS: Consultancy; Novartis: Consultancy; Axiom: Honoraria; Janssen: Consultancy; Celgene: Consultancy. Lonial:Novartis: Consultancy, Research Funding; Millennium: Consultancy, Research Funding; Onyx: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Celgene: Consultancy, Research Funding. Roodman:Amgen: Consultancy; Eli Lilly: Research Funding. Mortimer:AstraZeneca: Other: spouse is an employee of and has equity ownership in.

(P1-40) Development of Hospital Triage Training at the Chris Hani Baragwanath Hospital

Development of Hospital Triage Training at the Chris Hani Baragwanath Hospital F. Plani1, E Degiannis, P Lingham No disaster training had ever been carried out at the CHBH, the biggest hospital in the world with over 2900 beds and over 5000 staff members. The 2010 Disaster Plan required that all clinical staff undergo the appropriate training. Basic Interprofessional Training for Trauma Disasters 411 staff members attended a half day course during May/June 2010, presented and sponsored by CHBH Trauma Directorate consultants. The aims of the course were to disseminate the trauma disaster plan in interdisciplinary and interprofessional fashion, clarify hospital triage, familiarize staff with Trauma Unit equipment, and practice resuscitations in mass casualty incidents. The course started with presentations on CHBH Disaster Plans and Protocols and Principles of Triage and Standard of Care in Disasters. This was followed by 3 multiple patient scenarios with rotating groups, over a whole hospital floor with: 1) 50 mixed patients outside the hospital; 2) 10 serious patients in the ER; 3) 10 patients deteriorating later in a ward or ICU. Next were individual patient resuscitations, Primary, Secondary, Tertiary Survey and “hand-over”, patient resuscitations in a disaster, using the contents from “Disaster Bags” and questionnaires to assess confidence and suitable treatment areas (Red, Yellow, Green, OT) for allocation in a disaster. The course was wrapped up by a familiarization visit to ED and the colour coded areas.ResultsFinal questionnaires demonstrated that all participants were a lot more confident in the triage of patients and the initial resuscitation using the implements found in the resuscitation room and the “Disaster Bags”. The course has been adopted as part of staff orientation at all professional levels from 2011 onwards, and is in the process to be extended to secondary level hospitals in Gauteng, RSA.

Structured assessment using multiple patient scenarios by videoconference in rural settings

The assessment blueprint of the Australian College of Rural and Remote Medicine postgraduate curriculum highlighted a need to assess clinical reasoning. We describe the development, reliability, feasibility, validity and educational impact of an 8-station assessment tool, StAMPS (structured assessment using multiple patient scenarios), conducted by videoconference. StAMPS asks each candidate to be examined at each of 8 stations on issues relating to patient diagnosis or management. Each candidate remains located in a rural site but is examined in turn by 8 examiners who are located at a central site. Examiners were rotated through the candidates by either walking between videoconference rooms or by connecting and disconnecting the links. Reliability was evaluated using generalisability theory. Validity and educational impact were evaluated with qualitative interviews. Fourteen candidates were assessed on 82 scenarios with a reliability of G = 0.76. There was a reasonable correlation with level of candidate expertise (rho = 0.57). The videoconference links were acceptable to candidates and examiners but the walking rotation system was more reliable. Qualitative comments confirmed relevance and acceptability of the assessment tool and suggest it is likely to have a desirable educational impact. StAMPS not only reflects the content of rural and remote practice but also reflects the process of that work in that it is delivered from a distance and assesses resourcefulness and flexibility in thinking. The reliability and feasibility of this type of assessment has implications for people running any distance-based course, but the assessment could also be used in a face-to-face setting.

Developing the accredited postgraduate assessment program for Fellowship of the Australian College of Rural and Remote Medicine

Accreditation of the Australian College of Rural and Remote Medicine (ACRRM) as a standards and training provider, by the Australian Medical Council (AMC) in 2007, is the first time in the world that a peak professional organisation for rural and remote medical education has been formally recognised. As a consequence, the Australian Government provided rural and remote medicine with formal recognition under Medicare as a generalist discipline. This accreditation was based on the ability of ACRRM to meet the AMC's guidelines for its training and assessment program.The methodology was a six-step process that included: developing an assessment blueprint and a classification scheme; identifying an assessment model; choosing innovative summative and formative assessment methods that met the needs of rural and remote located medical practitioner candidates; 21 rural doctors and academics developing the assessment items as part of a week-long writing workshop; investigating the feasibility of purchasing assessment items; and 48 rural candidates piloting three of the assessment items to ensure they would meet the guidelines for national accreditation.The project resulted in an innovative formative and summative assessment program that occurs throughout 4 years of vocational training, using innovative, reliable, valid and acceptable methods with educational impact. The piloting process occurred for 3 of the 6 assessment tools. Structured Assessment Using Multiple Patient Scenarios (StAMPS) is a new assessment method developed as part of this project. The StAMPS pilot found that it was reliable, with a generalisability coefficient of >0.76 and was a valid, acceptable and feasible assessment tool with desired educational impact. The multiple choice question (MCQ) examination pilot found that the applied clinical nature of the questions and their wide range of scenarios proved a very acceptable examination to the profession. The web based in-training assessment examination pilot revealed that it would serve well as a formative process until ACRRM can further develop their MCQ database.The ACRRM assessment program breaks new ground for assessing rural and remote doctors in Australia, and provides new evidence regarding how a comprehensive and contemporary assessment system can work within a postgraduate medical setting.