A simulação como recurso pedagógico no ensino médico

Background: The use of simulation in medical education ensures improved learning and an increase in experience without the risk of real events. The absence of previous training in the execution of technical procedures may involve risks to the patient, inseparable from the technique in question. Thus, medical education is decisive in preventing medical errors, and simulation has a critical role in this field. Different approaches, such as mixed-realism scenarios, high-fidelity mannequins, and virtual reality, are used in simulation as resources for medical education. Simulation can be used to train technical and non-technical skills such as team endeavor, team communication, and clinician-patient communication. The latter, which includes the disclosure of an adverse event to a patient, contributes to the increase in the clinician's confidence. Although the recognition of simulation as a fundamental resource in medical education has been increasing in the last years, there is a lack of implemented courses, as part of pre- and post-graduate medical training, and quantitative evaluation of the impact of these courses in residency and, at ultimately, in patient care improvement. Objectives: To increase anesthesiology training's efficacy and safety by including simulation training as a mandatory component of Anesthesiology Residency. To accomplish this primary objective, the work was divided into three aims: 1) to train and evaluate, through the construction of an evaluation instrument divided into two-parts: the participation in a clinical episode that triggered an adverse event in a simulation scenario in an Operating Room context and the dissemination of the same adverse event, in a hybrid simulation scenario; 2) to design a skill training program, in a simulation environment according to the programmatic contents included in the Portuguese Residency in Anesthesiology including technical and non-technical skills; 3) to implement and evaluate the program through the construction and validation of self-assessment questionnaires answered by the residents before and after each simulation module. Results: The comprehensive methodology involving mixed-realism simulation engaged 42 Anesthesiology residents in an adverse event and its disclosure to the patient. It allowed practicing to a range of patients’ answers through the different stages of a grief response. The instruments to assess the performance and the anesthesiology residents' disclosure practice showed excellent interrater reliability and high internal consistency (p<0.05). Three-hundred and forty individuals attended the competencies training program for Portuguese Anesthesiology residents, designed according to the programmatic contents defined by the Portuguese Board of Anesthesiology: 76 from the first year, 89 from the second, 82 from the third, and 93 from the fourth and last year. For the evaluation of this program, self-assessment questionnaires to be applied before and after each simulation module were designed, and the internal consistency was tested, indicating a high internal consistency of all questionnaires. Students assessed the importance attributed to several main technical concepts in Anesthesiology, and their training and experience before and after each simulation course. The results were statistically significant in almost all comparisons (p<0.05). Likewise, these questionnaires also included questions regarding non-technical skills such as need for help, making mistakes, self-efficacy over time, need for support, communication, and team attitude. Over time, the need for support and the number of mistakes increased from the residents' perspective (p<0.001). However, the students assumed that, through the residency, there was an improvement in the communication skills since they easily expressed their opinion, even if they disagreed with the consultant anesthesiologist. Unanimity is highlighted regarding the importance of non-behavioral competencies for clinical practice excellence, identified by 4th-year residents at the end of training with simulation. Finally, the residents rated all the programmatic contents addressed during the simulation modules as highly important. The last year's topics were the ones with numerically higher importance attributed by the trainees. Conclusions: The evaluation instrument divided into two parts demonstrated solid psychometric properties to evaluate the performance of communication to the patient of the occurrence of an adverse effect. The mixed concept of reality-simulation allowed residents to be involved in an adverse event and train their communication before direct contact with a patient. The construction of a simulation program according to the Anesthesiology Residency's pedagogical contents improves training in this area without putting patients at risk. It has repercussions on recognizing the error, enriching the value of self-confidence and the fundamental role of behavioral skills.In the end, this study showed that simulation also has repercussions on the identification of gaps that must be overcome before the residents become independent, culminating in improved patient safety. Together, the results obtained emphasize the positive impact of simulation as a learning instrument of the Medical Residency in Anesthesiology.Introdução: O uso da simulação no ensino médico assegura uma melhoria na aprendizagem e um acréscimo de experiência, sem o risco dos eventos reais. A ausência de treino prévio na execução de procedimentos técnicos pode associar risco para o doente, indissociável da técnica em questão. Assim, a educação e o treino em segurança são decisivos para a prevenção do erro médico. Neste contexto, a simulação tem um papel determinante. Diferentes abordagens, como cenários híbridos realidade-simulação, manequins de altafidelidade e realidade virtual são usadas em simulação enquanto recurso de ensino médico. A simulação pode ser utilizada na aquisição de competências técnicas e competências não técnicas, como o trabalho de equipa, a comunicação em equipa e a comunicação médicodoente. A relação médico-doente pode também ser desenvolvida pelo treino de situações como a comunicação de um evento adverso a um doente ou familiar. Embora o reconhecimento da simulação como instrumento fundamental na educação médica tenha aumentado nos últimos anos, falta ainda a sua integração na formação médica pré e pós-graduada, tal como a avaliação quantitativa dessa integração no desempenho dos médicos internos e, em última instância, na melhoria assistencial do doente. Objetivos: Aumentar a eficácia e a segurança da formação em Anestesiologia através da inclusão do treino em simulação como componente obrigatória do programa de formação específica desta especialidade. Para atingir esse objetivo principal, o trabalho foi dividido em três objetivos secundários: 1) Treinar e avaliar, através da construção de um instrumento de avaliação dividido em duas partes: a participação num episódio clínico que desencadeou um efeito adverso num cenário de simulação em contexto de bloco operatório e a divulgação do mesmo evento adverso, num cenário híbrido de simulação; 2) desenhar um programa de formação de competências, em ambiente de simulação, de acordo com os conteúdos programáticos incluídos no Internato de Anestesiologia, incluindo competências técnicas e não técnicas; 3) implementar e avaliar o programa através da construção e validação de questionários de autoavaliação respondidos pelos internos antes e depois de cada curso de simulação. Resultados: A metodologia que envolveu a utilização da técnica de simulação mista realidade-simulação contou com a participação de 42 internos de Anestesiologia na simulação de um evento adverso e na sua comunicação ao doente. Este estudo permitiu a prática de um conjunto de respostas aos doentes ao longo das diferentes fases do luto. Os instrumentos para avaliar o desempenho e a prática da comunicação do efeito adverso pelos internos de Anestesiologia, apresentaram uma excelente fiabilidade e elevada consistência interna (p<0,05). O programa de formação de competências para internos portugueses de Anestesiologia, desenhado de acordo com os conteúdos programáticos definidos pelo Colégio de Anestesiologia da Ordem do Médicos, contou com a participação de 340 médicos: 76 internos do primeiro ano, 89 do segundo, 82 do terceiro e 93 do quarto e último ano. Para a avaliação deste programa foram construídos questionários de autoavaliação para serem aplicados antes e depois de cada módulo do programa de simulação. A consistência interna foi testada e considerada elevada em todos os questionários. Os participantes avaliaram a importância atribuída a diversos conceitos técnicos em Anestesiologia, e a sua formação e experiência antes e depois de cada curso de simulação. Os resultados foram estatisticamente significativos na maioria das comparações (p<0,05). Da mesma forma, os questionários permitiram autoavaliar a evolução do desempenho clínico e competências não técnicas, tais como a consciência situacional, o pedido de ajuda, a comunicação e o trabalho de equipa. Ao longo do tempo, na perspetiva dos internos, a necessidade de apoio e o número de erros aumentaram (p<0,001). Os médicos internos assumiram também que ao longo do internato houve uma melhoria da capacidade de comunicação, uma vez que mais facilmente expressam a sua opinião, mesmo discordando do anestesiologista sénior. Realça-se a unanimidade em relação à importância das competências não comportamentais para a excelência da prática clínica, identificada pelos internos do 4º ano no final das formações com simulação. Por fim, os participantes deram elevada importância a todos os conteúdos programáticos abordados durante os módulos de simulação, com maior relevância nos temas abordados no último ano. Conclusões: O instrumento de avaliação dividido em duas partes demonstrou fortes propriedades psicométricas para avaliar o desempenho da comunicação ao doente da ocorrência de um efeito adverso. O conceito misto de realidade-simulação permitiu que os internos estivessem envolvidos num evento adverso e treinassem a sua comunicação antes do contato direto com um doente. A construção de um programa de simulação de acordo com os conteúdos pedagógicos do Internato de Anestesiologia melhora não só a formação nesta área, sem colocar os doentes em risco, como tem repercussão no reconhecimento do erro, enriquecendo o valor da autoconfiança e o papel fundamental das competências comportamentais. No final, este estudo mostrou que a simulação também tem repercussão na identificação de lacunas que devem ser ultrapassadas antes que os internos se tornem independentes, culminando na melhoria da segurança do doente. Em conjunto, os resultados obtidos vêm enfatizar o impacto positivo da simulação como instrumento de aprendizagem do Internato Médico de Anestesiologia

Development and Evaluation of an Internet-Based Airway Evaluation Tutorial

Airway evaluation and basic management are essential skills for all physicians. Identifying patients for whom mask ventilation or endotracheal intubation will be difficult to impossible is vital for patient safety. Despite this, training in airway evaluation is minimal in the curricula of most medical schools. To ensure a thorough understanding of airway anatomy and evaluation, as well as exposure to various abnormal findings, we developed an Internet-based module including interactive components, graphics, animation, video, and a self-assessment tool. The site received more than 1800 visits in its first nine months of operation, with uniformly laudatory comments. Eighty subjects over a six-month period completed a pre- and post-test quiz structured to evaluate the utility of the site. Of those completing the on-line survey, more than 76% rated the site very useful. Most felt their knowledge of airway examination improved after completion of the site (p<0.00004). The median amount of time spent on the site was 29.5 minutes. Judging from the overwhelming response to this site from around the world and across disciplines, such interactive training tools that exploit the technological capabilities of the Internet provide useful adjuncts to traditional teaching methods

Developing Technical Expertise in Emergency Medicine—The Role of Simulation in Procedural Skill Acquisition

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72919/1/j.1553-2712.2008.00218.x.pd

Efficacy of double-lumen intubation performed by paramedics on patients with lung damage. Experimental, pilot simulation trial

INTRODUCTION: The airway management and the implementation of optimal oxygen therapy in trauma patients, especially unconscious ones, is a key element of prehospital management. However, in cases of trauma lung or bronchial rupture, both lungs ventilation may not be advisable. In such cases, intubation with a double-lumen endotracheal tube may be helpful, allowing to provide one-lung ventilation. The aim of the experimental study was to assess the impact of short training in intubation using double-lumen tubes on the effectiveness of intubation performance and one-lung ventilation by paramedics in a simulated trauma patient setting. MATERIAL AND METHODS: This was a prospective, observational, randomized experimental trial. The study involved 30 paramedics. The participants had to perform tracheal intubation using Double Lumen Tube VivaSight-DL (VS-DL; ETView Ltd.; Misgav, Israel) under normal airway conditions. The effectiveness of the first intubation attempt, the time of intubation and the Cormack-Lehane scale were evaluated. RESULTS: The effectiveness of the first attempt at intubation with a double-lumen tube was 90% and the total effectiveness of intubation was 100%. The median time of the procedure was 63 (IQR; 38–72.5) seconds. CONCLUSIONS: In the simulation study, the paramedics were able to intubate using a double tube after a short training

Airway skills training using a human patient simulator

Background: Airway skills education is important for the safe and effective care of patients. Interns often encounter critical airway situations. Their ability to cope derives from the recall of formal lectures and tutorials, as well as accumulated experience. We tested whether human patient simulators enabled trainees to enhance skills and knowledge in a safe and realistic environment.Method: An airway training programme was developed using a high-fidelity lifelike human patient simulator (METI®) to simulate realistic airway scenarios. An equivalent programme using traditional methods (lectures and tutorials) contained the same information. A written assessment [(multiple-choice questions (MCQ)] and four assessment stations [objective structured clinical examination (OSCE)] were administered before and after instruction. A questionnaire documented previous exposure to the simulator, airway management techniques and devices, and participants’ subjective opinions on the instruction received.Results: Eighty-two participants were enrolled into two groups of 41. Groups were comparable in terms of previous exposure and experience, as well as in pre-training scores. Both groups showed significant improvement in post-training scores. However, subjects receiving simulator training achieved significantly higher test scores in the MCQ (median 43 out of 50, interquartile range (IQR) 42 45, versus 41 out of 50, IQR 39–43); and OSCE assessment station 3 (median 15 out of 15, IQR 13–15, versus 14 and 12–15), and OSCE assessement station 4 (median 13 out of 15, IQR 12–14, versus 12 and 10–13). The simulator group showed greater participant satisfaction (95% vs. 34%).Conclusion: There was improved immediate retention of knowledge and performance of airway management skills using the simulator. Participant satisfaction was much better in the simulator group. The importance of psychomotor reinforcement should be borne in mind when designing simulation courses.Keywords: human patient simulator, simulation, airway management, psychomotor skill

The Effect of High-Fidelity Manikin-Based Human Patient Simulation on Educational Outcomes in Advanced Cardiovascular Life Support Courses

The use of high-fidelity manikin-based simulation has been studied in many healthcare education areas. However, the use of this education technology in the American Heart Association Advanced Cardiovascular Life Support (ACLS) course has not been well examined in the literature, despite this education program being one of the most widely taught standardized medical courses in the United States. This study examined high fidelity manikin-based simulation versus low-fidelity manikin-based simulation in the context of an actual ACLS course. Four outcomes were measured: learning outcomes as judged by an expert rater panel reviewing videos of subjects performing a simulated cardiac arrest event immediately after the conclusion of the course, and three self-reported measures examining confidence with the course material, motivation, and affect. A convenience sample of 34 subjects self assigned to one of two ACLS classes. One class utilized high-fidelity simulation (n=16) while the other used low-fidelity simulation (n=18). While the high-fidelity simulation group had a higher composite score for the video review (M= 220.88 vs. M=193.67), this did not reach a level of significance (p=.122). On item level analysis of the scoring, 7 of 14 items reached levels of significance (p \u3c .05). Although all items reported higher mean scores for the highfidelity simulation group, items that focused on manual tasks or actions in the first one to two minutes of the cardiac arrest event were more likely to be non-significant. Items that focused on actions that occurred later in the event or were expert rater assessments of team leader confidence and knowledge were more likely to be found significant. There was no statistical significance found in any of the self-reported measures examining confidence (p = .850), motivation (p = .899), and affect (p = .215)

Code Blue: methodology for a qualitative study of teamwork during simulated cardiac arrest.

IntroductionIn-hospital cardiac arrest (IHCA) is a particularly vexing entity from the perspective of preparedness, as it is neither common nor truly rare. Survival from IHCA requires the coordinated efforts of multiple providers with different skill sets who may have little prior experience working together. Survival rates have remained low despite advances in therapy, suggesting that human factors may be at play.Methods and analysisThis qualitative study uses a quasiethnographic data collection approach combining focus group interviews with providers involved in IHCA resuscitation as well as analysis of video recordings from in situ-simulated cardiac arrest events. Using grounded theory-based analysis, we intend to understand the organisational, interpersonal, cognitive and behavioural dimensions of IHCA resuscitation, and to build a descriptive model of code team functioning.Ethics and disseminationThis ongoing study has been approved by the IRB at UC Davis Medical Center.ResultsThe results will be disseminated in a subsequent manuscript

Use of simulation training to teach the ABCDE primary assessment:an observational study in a Dutch University Hospital with a 3-4 months follow-up

Objectives To investigate short-term and long-term effectiveness of simulation training to acquire a structured Airway Breathing Circulation Disability Exposure (ABCDE) approach for medical emergencies; and to examine which skills were learnt and maintained best. Design An observational study with a 3-4 months follow-up. Setting Skills center of the University Medical Center Groningen. Participants Thirty voluntary participants (21 females and 9 males; 27±2.77 years) of a simulation-based course. Intervention A 2-day ABCDE-teaching course for residents and non-residents. The course encompasses 24 simulations in which participants perform primary assessments of acute ill patients. Video recordings were taken of each participant performing a primary assessment, before (T1), directly after (T2) and 3-4 months after the intervention (T3). Main outcome measures Physicians' performance in the ABCDE primary assessment at T1, T2 and T3. Two observers scored the primary assessments, blinded to measurement moment, using an assessment form to evaluate the performance with regard to skills essential for a structured ABCDE approach. The Friedman and Wilcoxon signed-rank test were used to compare physicians' performances on the subsequent measurement moments. Results The mean ranks on the total primary assessment at T1, T2 and T3 were 1.14, 2.62 and 2.24, respectively, and were significantly different, (p<0.001). The mean ranks on the total primary assessment directly after the course (T2 vs T1 p<0.001) and 3-4 months after the course (T3 vs T1 p<0.001) were significantly better than before the course. Certain skills deteriorated during the follow-up. Strikingly, most skills that decrease over time are Crew Resources Management (CRM) skills. Conclusion A course using simulation training is an effective educational tool to teach physicians the ABCDE primary assessment. Certain CRM skills decrease over time, so we recommend organising refresher courses, simulation team training or another kind of simulation training with a focus on CRM skills