Edukacija temeljena na simulacijama regionalne anestezije

Simulation-based training is a technique, which uses technological devices to reproduce different clinical situations like in the real world. Procedures and simulation scenarios performed on simulators can be planned and repeated with no harm for the patient. Simulation-based training introduced new educational applications in medicine to improve patient safety. Simulation education was introduced in the anesthesia curriculum in 2017 as a first specialization in Slovenia.Simulacijska edukacija je tehnika koja koristi tehnološku opremu da ustvari različite kliničke situacije kao u stvarnim kliničnim uvjetima. Zahvati i različiti scenariji izvedeni na simulatorima se mogu planirati i ponavljati bez opasnosti za pacijenta. Simulacijsko učenje uvodi nove edukacijske metode u medicinu kako bi se unaprijedila sigurnost u tretmanu pacijenata. U slovenski kurikulum specijalizacije iz Anesteziologije,reanimatologije i perioperativne intenzivne medicine je simulacijsko učenje uvedeno godine 2017 kao prvo u Sloveniji

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

A comprehensive description of the competencies required for the performance of an ultrasound-guided axillary brachial plexus blockade

We addressed four research questions, each relating to the training and assessment of the competencies associated with the performance of ultrasound-guided axillary brachial plexus blockade (USgABPB). These were: (i) What are the most important determinants of learning of USgABPB? (ii) What is USgABPB? What are the errors most likely to occur when trainees learn to perform this procedure? (iii) How should end-user input be applied to the development of a novel USgABPB simulator? (iv) Does structured simulation based training influence novice learning of the procedure positively? We demonstrated that the most important determinants of learning USgABPB are: (a) Access to a formal structured training programme. (b) Frequent exposure to clinical learning opportunity in an appropriate setting (c) A clinical learning opporunity requires an appropriate patient, trainee and teacher being present at the same time, in an appropriate environment. We carried out a comprehensive description of the procedure. We performed a formal task analysis of USgABPB, identifying (i) 256 specific tasks associated with the safe and effective performance of the procedure, and (ii) the 20 most critical errors likely to occur in this setting. We described a methodology for this and collected data based on detailed, sequential evaluation of prototypes by trainees in anaesthesia. We carried out a pilot randomised control trial assessing the effectiveness of a USgABPB simulator during its development. Our data did not enable us to draw a reliable conclusion to this question; the trail did provide important new learning (as a pilot) to inform future investigation of this question. We believe that the ultimate goal of designing effective simulation-based training and assessment of ultrasound-guided regional anaesthesia is closer to realisation as a result of this work. It remains to be proven if this approach will have a positive impact on procedural performance, and more importantly improve patient outcomes

The ultrasound use of simulators, current view, and perspectives: Requirements and technical aspects (WFUMB state of the art paper)

Simulation has been shown to improve clinical learning outcomes, speed up the learning process and improve learner confidence, whilst initially taking pressure off busy clinical lists. The World Federation for Ultrasound in Medicine and Biology (WFUMB) state of the art paper on the use of simulators in ultrasound education introduces ultrasound simulation, its advantages and challenges. It describes different simulator types, including low and high-fidelity simulators, the requirements and technical aspects of simulators, followed by the clinical applications of ultrasound simulation. The paper discusses the role of ultrasound simulation in ultrasound clinical training, referencing established literature. Requirements for successful ultrasound simulation acceptance into educational structures are explored. Despite being in its infancy, ultrasound simulation already offers a wide range of training opportunities and likely holds the key to a broader point of care ultrasound education for medical students, practicing doctors, and other health care professionals. Despite the drawbacks of simulation, there are also many advantages, which are expanding rapidly as the technology evolves

Training in and assessment of the procedural skills required to perform peripheral nerve blockade

The training and ongoing education of medical practitioners has undergone major changes in an incremental fashion over the past 15 years. These changes have been driven by patient safety, educational, economic and legislative/regulatory factors. In the near future, training in procedural skills will undergo a paradigm shift to proficiency based progression with associated requirements for competence-based programmes, valid, reliable assessment tools and simulation technology. Before training begins, the learning outcomes require clear definition; any form of assessment applied should include measurement of these outcomes. Currently training in a procedural skill often takes place on an ad hoc basis. The number of attempts necessary to attain a defined degree of proficiency varies from procedure to procedure. Convincing evidence exists that simulation training helps trainees to acquire skills more efficiently rather than relying on opportunities in their clinical practice. Simulation provides a safe, stress free environment for trainees for skill acquisition, generalization and transfer via deliberate practice. The work described in this thesis contributes to a greater understanding of how medical procedures can be performed more safely and effectively through education. The effect of feedback, provided to novices in a standardized setting on a bench model, based on knowledge of performance was associated with an increase in the speed of skill acquisition and a decrease in error rate during initial learning. The timing of feedback was also associated with effective learning of skill. A marked attrition of skills (independent of the type of feedback provided) was demonstrable 24 hrs after they have first been learned. Using the principles of feedback as described above, when studying the effect of an intense training program on novices of varied years of experience in anaesthesia (i.e. the present training programmes / courses of an intense training day for one or more procedures). There was a marked attrition of skill at 24 hours with a significant correlation with increasing years of experience; there also appeared to be an inverse relationship between years of experience in anaesthesia and performance. The greater the number of years of practice experience, the longer it required a learner to acquire a new skill. The findings of the studies described in this thesis may have important implications for the trainers, trainees and training bodies in the design and implementation of training courses and the formats of delivery of changing curricula. Both curricula and training modalities will need to take account of characteristics of individual learners and the dynamic nature of procedural healthcare

Evaluation of a Patient-Specific, Low-Cost, 3-Dimensional–Printed Transesophageal Echocardiography Human Heart Phantom

Simulation based education has been shown to increase the task-specific capability of medical trainees. Transesophageal echocardiography training greatly benefits from the use of simulators. They allow real time scanning of a beating heart and generation of ultrasound images side by side with anatomically accurate virtual model. These simulators are costly and have many limitations. 3D printing technologies have enabled the creation of bespoke phantoms capable of being used as task-trainers. This study aims to compare the ease of use and accuracy of a low-cost patient-specific, Computer-tomography based, 3D printed, echogenic TEE phantom compared to a commercially available echocardiography training mannequin. We hypothesized that a low-cost, 3D printed custom-made, cardiac phantom has comparable image quality, accuracy and usability as existing commercially available echocardiographic phantoms. After Institutional Ethic Research Board approval, we recruited ten American Board – Certified cardiac anesthesiologists and conducted a blinded comparative study divided into two stages. Stage one consisted of image assessment. A set of basic TEE views obtained from the 3D printed and commercial phantom were presented to the participants on a computer screen in random order. For each image, participants will be asked to identify the view, identify the quality of the image on a 1-5 Likert scale compared to the corresponding human view and guess with which phantom it was acquired (1 not at all realistic to patients view and 5 realistic to patients view). Stage two, participants will be asked to use the 3D printed and the commercially available phantom to obtain basic TEE views. In a maximum of 30 minutes. Each view was recorded and assessed for accuracy by two certified echocardiographers. Time needed to acquire each basic view and number of correct views was recorded. Overall usability of the phantoms was assessed through a questionnaire. For all continuous variables, we will calculate mean, median and standard deviation. We use Wilcoxon Signed-Rank test to assess significant differences in the rating of each phantom. All ten participants completed all part of the study. All participants could recognize all of the standard views. The average Likert scale was 3.2 for the 3D printed and 2.9 for the commercial Phantom with no significant difference. The average time to obtain views was 24.5 and 30 sec for the 3D printed and the commercial phantoms respectively statistically significantly in favor of the 3D printed phantom. The qualitative user assessment for ease to obtain the views, probe manipulation, image quality and overall experience were in great favor of the 3D printed phantom. Our Study suggest that the quality of TEE images obtained on the 3D printed phantom are not significantly different from those obtained on the commercial Phantom. The ease of use and time required to complete a basic TEE exam were in favor of the 3D Printed phantom.:Table of Content 1. Bibliographic Description 3 2. Introduction 4 2.1. Perioperative transesophageal echocardiography 4 2.2. Transesophageal echocardiography training 5 2.3. Transesophageal echocardiography simulation 6 2.4. 3D Heart Printing 13 2.5. 3D Segmentation 16 2.6. Development of the study phantom 17 2.7. Study Rationale 18 3. Publication 22 4. Summary 30 5. References 33 6. Appendices 37 6.1. Darstellung des eigenes Beitrags 38 6.2. Erklärung über die eigenständige Abfassung der Arbeit 39 6.3. Lebenslauf 40 6.4. Publikationen und Vorträge 44 6.5. Danksagung 61