Pa#ent simula#on to teach resuscita#on skills for medical trainees Introduction: There has been always a concern whether what we learn in schools and classroom will help us in real life. In medical school this ques9on is even more important; different skills students learn will help them save lives and improve pa9ents’ quali9es of life. For decades the instruc9onal methods in medical school were decontextualized from actual pa9ent encounters and experimenta9on except for short lab 9mes and hospital visits for bedside teaching. When these issues are raised and discussed on departmental mee9ngs the usual excuse to con9nue the old ways are mostly poli9cal and organiza9onal rather than ignorant or denial. There are huge numbers of medical students and less numbers of actual pa9ents per student, there is also a difficulty in training students how to deal with life threatening condi9ons where the decision should be rapid and conclusive, life threatening emergencies are not common presenta9on to hospitals and emergency departments, especially when it comes to pediatric hospitals. It is difficult to teach during a life‐threatening emergency, which is what leads the most experienced physician to take over whenever a cri9cally sick pa9ent arrives to the department All these factors kept the instruc9onal methods in modern medical schools more dependent on texts, lectures and tutorials more than clinical and experimental methods The introduc9on of simula9on technologies in medicine gave an insighHul hope to use it in medical educa9on to teach skills and simulate real life scenarios in aIempts to remove some of these obstacles from medical students’ curricula. These technologies allowed medical educators to teach resuscita9on skills in a simulated environment that is safe, s9mula9ng, immersive and almost realis9c in nature without the anxiety about harming the pa9ent in the learning process.
Medical educators’ interest in simula9on is based on different reasons: Perkins (2007) summarized 10 affordances of high fidelity simula9on that helps in crea9ng effec9ve learning: 1. Providing feedback 2. Repe99ve prac9ce 3. Curriculum integra9on 4. Range of difficulty level 5. Mul9ple learning strategies 6. Capture clinical varia9on 7. Controlled environment 8. Individualized learning 9. Defined outcomes 10. Simulator validity Perkins (2007) also summarized how the use of simula9on can be looked at from different theore9cal perspec9ves: The Behaviorists will look at the ability to provide feedback during the process of skill acquisi9on, the construc9vists claim that new challenges and experiences learners face in the simulated environment help them construct and create meaning. Social theorists talk about the importance of context and community prac9ce within the simulated environments which supports the concept of legi9mate peripheral par9cipa9on where the novice learner moves within a community of prac9ce from peripheral to full par9cipa9on S9mula9on technologies have been used in medicine for more than 40 years, but only got popular in the last 15 years (Bradely, 2006). A worldwide survey has iden9fied 158 simula9on
centers (Morgan and cleave‐Hogg, 2002) that use different simula9on technologies in medical educa9on among which is the Human Pa9ent Simulator (HPS). The Human Pa9ent Simulator is a high‐fidelity manikin that comes in different sizes (infant, Child, adult). These manikins are connected to advanced computer systems that send and receive signals from the manikins during the training exercises. With its advanced technology, the HPS can behave and respond similar to sick pa9ents in different situa9ons, the feedback the manikin gives to the trainees during the training session depends on the decisions made by the trainees
The use of Human Pa9ent Simulators (HPS) in medical schools and hospitals is a rapidly increasing phenomenon. This advanced simula9on technology is aimed to provide high quality teaching to medical trainees in an interac9ve, hands‐on workshops. Its use has expanded drama9cally to most fields of medicine including Radiology, Obstetrics, Emergency and Nursing (Issenberg1999) There are mul9ple technologies and ways of using simula9on in medical educa9on, ranging from simple devices to teach specific procedures to very complex High‐fidelity manikins that simulate real pa9ents. We use the Human Pa9ent Simulator in the Center of Excellence at Vancouver General Hospital on a weekly basis to teach medical trainees and nurses the skills of resuscita9on But, even with these great affordances that sound convincing, when it comes to the costs associated with buying, using and maintaining these devices, they are very pricy which will always bring the ques9on of cost effec9veness. Hospital administrators are always asking for
evidence to support any request of funding such projects asking about the differences between the tradi9onal methods of instruc9ons and the simula9on technologies. Some authors argued that there is no enough evidence to support that simula9on actually improves the performance during real situa9ons (Girard and Drolet, 2002) The ques9on of interest becomes then, what is the evidence that using simula9on in emergency medicine educa9on lead to beIer mastery of cri9cal resuscita9on skills and transfer of these skills to actual life‐threatening situa9ons?, Will simula9on teaching improve the performance and competency of medical trainees when they deal with sick pa9ents? Is this effect superior to the tradi9onal educa9on of case based scenarios, tutorials and lectures? As an emergency doctor, I am interested to answer few ques9ons related to the use of simula9on in my field: First I want to know if there is a gap in resuscita9on training in terms of skills acquisi9on and transfer Second: I want to know how the use of simula9on technology can help us fill any exis9ng gap in performance
To help focus my search, I combined these ques9ons into one ques9on of interest: Does Pa9ent Simula9on training improve resuscita9on skills for physicians and nurses?. I am interested in having these ques9ons answered as I am planning to establish the first simula9on center in my city when I go back to my country 2 years from now.
Research Review: Search Strategy: I searched both OVID database and PubMed to find the ar9cles in my review. Both OVID and PubMed are considered the main Medline search engines for Health care related disciplines I accessed OVID gateway through UBC library. I searched all OVID Medline database between 1950 to present 9me. OVID MeSH (Medical subject heading) is an excellent tool to search for big themes in isola9on before combining them in one search. I ini9ally searched for the MeSH ‘simula9on’ which revealed 4 different MeSHs in OVID database from which I only chose Pa9ent Simula9on. The search revealed 1306 ar9cles I then searched the MeSH Resuscita9on to find 4 different categories from which I included Cardiopulmonary resuscita9on and resuscita9on (24635 ar9cles) Aier combining the both searches, I ended up with 29 ar9cles that combined pa9ent simula9on AND cardiopulmonary resuscita9on OR resuscita9on I pulled the abstracts of these ar9cles and excluded the ones that are not rela9ve to my ques9on to end up with 12 ar9cles The second step of my search to find more ar9cles was to search PubMed, the other popular Medline search engine. In addi9on to searching Medline, PubMed searches: The out‐of‐scope cita9ons (e.g., ar9cles on plate tectonics or astrophysics) from certain MEDLINE journals, primarily general science and chemistry journals, for which the life sciences ar9cles are indexed for MEDLINE.
Cita9ons that precede the date that a journal was selected for MEDLINE indexing. Some addi9onal life science journals that submit full text to PubMed Central and receive a qualita9ve review by NLM I Searched the words ‘Simulat*’ AND ‘Resuscitat*’ to be able to include different combina9ons (e.g.’ simula9on, simulator, Resuscita9on and resuscitator) in my search. The combined the search revealed 70 ar9cles. All the 29 ar9cles from the OVID search were included in PubMed search but, in addi9on, I found, aier reviewing all the abstracts, 11 ar9cles that were rela9ve to my search Literature review: The Gap in Resuscita/on training: Different studies suggested that there is a gap in our exis9ng training. Nadel (2000) evaluated Pediatric residents. technical skills, knowledge and perceived confidence Dealing with pediatric resuscita9on. The study took place in a large ter9ary pediatric hospital, designated a level‐1 trauma center, and a regional and interna9onal referral center for pediatric subspecialty care. The third‐ year residents had completed a pediatric advanced life support course in July of their first year and again in October of their third year of training. The study took place in March of the third year. The residents completed the standard pediatric advanced life support examina9on and 12 short‐answer ques9ons. Technical skills were assessed as the resident performed four advanced resuscita9on procedures, including airway maneuvers, endotracheal intuba9on, intraosseous needle placement, and femoral vein access using the Seldinger technique. The residents performed well on the cogni9ve por9on, with a mean score
on the pediatric advanced life support examina9on of 93.2%. When it came to performance of technical skills like airway management and intraosseous needle aspira9on, residents performed poorly with only 18%‐33% being able to perform these skills correctly White (2000) studied a total of 45 pediatric residents previously trained in pediatric advanced life support. He observed and scored four key resuscita9on skills (bag‐valve mask ven9la9on, endotracheal intuba9on, intraosseous catheter placement, defibrilla9on) and tested with four wriIen scenarios. Regardless of experience or year of training, the residents performed well on the wriIen exam, with a score of 5 (range,1–5). More than 80% of the trainees achieved the primary end point of a resuscita9ve skill but performed poorly on the subcomponents of each skill. For example, 39 residents (87%) were able to place the endotracheal tube into the mannequin trachea, but only 2 7 % checked for func9oning suc9on equipment before intuba9on and only 15% ensured bag‐valve mask equipment was available. When a scenario required defibrilla9on, most residents could discharge the defibrillator (89%), but only 12 (25%) chose the asynchronous mode for a pa9ent in ventricular fibrilla9on. A recent study by Hunt (2008) used simulators to further evaluate this gap in pediatric resuscita9on. He examined 34 hospital based mock codes using a mannequin or computerized simulator to enact unannounced, simulated crisis situa9ons involving children with respiratory distress or insufficiency, respiratory arrest, hemodynamic instability, and/or cardiopulmonary arrest. Assessment included 9me elapsed to ini9a9on of specefic resuscita9on maneuvers and devia9on from American Heart Associa9on guidelines. Among the 34 mock codes, the median 9me to assessment of airway and breathing was 1.3 minutes, to administra9on of oxygen was 2.0 minutes, to assessment of circula9on was 4.0
minutes, to arrival of any physician was 3.0 minutes, and to arrival of first member of code team was 6.0 minutes. Among cardiopulmonary arrest scenarios, elapsed 9me to ini9a9on of compressions was 1.5 minutes and to request for defibrillator was 4.3 minutes. In 75% of mock codes, the team deviated from American Heart Associa9on pediatric basic life support protocols, and in 100% of mock codes there was a communica9on error. They concluded that alarming delays and devia9ons occur in the major components of pediatric resuscita9on. Future educa9onal and organiza9onal interven9ons should focus on improving the quality of care delivered during the first 5 minutes of resuscita9on. Simula9on of pediatric crises can iden9fy targets for educa9onal interven9on to improve pediatric cardiopulmonary resuscita9on Can Simula/on training fill this gap? Different studies showed that simula9on training help teach resuscita9on skills. Rosenthal (2006) examined Forty‐nine internal medicine interns all of whom had been cer9fied in advanced cardiac life support. All interns were tested and scored with a computer based simula9on while responding to a standardized Respiratory arrest scenario. Random alloca9on to either training by a single experienced teaching aIending or by a housestaff team occurred immediately following tes9ng. All interns were retested using the same scenario 6 weeks following the ini9al training, and their clinical performance of airway management was scored during actual pa9ent events throughout the year. For 10 consecu9ve months following training, intern airway management scores were recorded for actual pa9ent airway events. All interns showed improvement in their airway skills both on retes9ng with the pa9ent simulator and in
actual pa9ent situa9ons. Interns trained by a house staff team performed as well as interns trained by the aIending.
The BRESUS report collected data from selected hospitals in the UK prior to the introduc9on of standardized resuscita9on training. Overall survival to hospital discharge was 17%, with pa9ents requiring defibrilla9on having a survival rate of 21%. Ten years later 50,000 healthcare professionals had received simula9on training in resuscita9on as part of the ALS course. Survival to discharge in the 1997 UK na9onal audit demonstrated a slight increased in overall survival, but a drama9c increase in survival for pa9ents with shockable rhythms (43% survival). Kory (2007) compared two groups of PGY3 internal medicine residents at an urban teaching hospital. One group (n: 32) received training in ini9al airway management skills using SBT with CPS in their PGY1 (i.e., the simula9on‐trained group. The second group (n: 30) received tradi9onal residency training (i.e., the tradi9onally trained group). Each group was then tested during PGY3 in ini9al airway management skills using a standardized respiratory arrest scenario. The ST group performed significantly beIer than the TT group in 8 of the 11 steps of the respiratory arrest scenario. Notable differences were found in the ability to aIach a bag‐valve mask (BVM) to high‐flow oxygen (ST group, 69%; TT group, 17%; p < 0.001), correct inser9on of oral airway (ST group, 88%; TT group, 20%; p < 0.001), and achieving an effec9ve BVM seal (ST group, 97%; TT group, 20%; p < 0.001). He concluded that Tradi9onal training consis9ng of 2 years of clinical experience was not sufficient to achieve proficiency in ini9al airway management skills, mostly due to inadequate equipment usage and that Simula9on based training is more effec9ve in training medical residents than the tradi9onal experien9al method.
Summary/Conclusion: Simula9on based training is effec9ve in teaching resusucita9on skills to residents and students. There is some evidence that it is superior to the tradi9onal instruc9onal methods. Simula9on takes in account individualized learning styles and differences, encourages trial and experimenta9on, provides immediate feedback and most importantly enhanced by the social context it occurs within.
References: Bradley P. (2006) The history of simulation in medical education and possible future directions. Med Educ 2006; 40:2 54—62. 31. Brett-Fleegler MB, Vinci RJ, Weiner DL, Harris SK, Shih MC, Kleinman ME (2008).A Simulator-Based Tool That Assesses Pediatric Resident Resuscitation Competency. Pediatrics. De Vita MA, Schaefer J, Lutz J, Wang H, Dongelli T. (2005). Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Qual Saf Health Care: 14(5): 326-31. DeVita M.(2005). Organizational factors affect human resuscitation: the role of simulation in resuscitation research.[comment]. [Comment. Editorial] Critical Care Medicine. 33(5):1150-1. Fiedor ML.(2004). Pediatric simulation: a valuable tool for pediatric medical education. Critical Care Medicine. 32(2 Suppl):S72-4.
Gilfoyle E. Gottesman R. Razack S. (2007). Development of a leadership skills workshop in paediatric advanced resuscitation. Medical Teacher. 29(9):e276-83. Girard M, Drolet P.(2002). Anaesthesiology simulators: networking is the key. Can J Anaesth; 49 (7):647â&#x20AC;&#x201C;9 Grenvik A. Schaefer J. (2004).From Resusci-Anne to Sim-Man: the evolution of simulators in medicine. Critical Care Medicine. 32:S56-7. Halamek LP. Kaegi DM. Gaba DM. Sowb YA. Smith BC. Smith BE. Howard SK. (2000). Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics. 106(4): E45. Hogan MP, Pace DE, hapgood J, Boone DC. (2006). Use of human patient simulation and the situation awareness global assessment technique in practical trauma skills assessment. J Trauma. 2006 Nov;61(5):1047-52. Holcomb JB. Dumire RD. Crommett JW. Stamateris CE. Fagert MA. Cleveland JA. Dorlac GR. Dorlac WC. Bonar JP. Hira K. Aoki N. Mattox KL.(2002). Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training. Journal of Trauma-Injury Infection & Critical Care. 52(6):1078-85; 1085-6. Hunt EA. Walker AR. Shaffner DH. Miller MR. Pronovost PJ.(2008). Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. Pediatrics. 121(1):e34-43.
Issenberg S, McGaghie W, Hart I, (1999). Simulation technology for health care professional skills training and assessment. JAMA ;282(9):861 â&#x20AC;&#x201C; 6 Kory PD. Eisen LA. Adachi M. Ribaudo VA. Rosenthal ME. Mayo PH. (2007). Initial airway management skills of senior residents: simulation training compared with traditional training. Chest. 132(6): 1927-31. Lighthall GK. (2006). The value of simulation training during anesthesia residency. Anesthesiology. 105(2): 433 Long RE.(2005). Using simulation to teach resuscitation: an important patient safety tool. Critical Care Nursing Clinics of North America. 17(1):1-8. Monsieurs KG. De Regge M. Vogels C. Calle PA.(2005). Improved basic life support performance by ward nurses using the CAREvent Public Access Resuscitator (PAR) in a simulated setting. Resuscitation. 67(1):45-50. Morgan P, Cleave-Hogg D.(2002). A worldwide survey of the use of simulation in anaesthesia. Can J Anaesth ;49 (7):659â&#x20AC;&#x201C;62. Perkins GD. (2007). Simulation in resuscitation training. Resuscitation. 73(2):202-11. Perkins GD. Augre C. Rogers H. Allan M. Thickett DR. (2005). CPREzy: an evaluation during simulated cardiac arrest on a hospital bed. Randomized Controlled Trial. Research Support, NonU.S. Gov't. Resuscitation. 64(1):103-8.
Rosenthal ME. Adachi M. Ribaudo V. Mueck JT. Schneider RF. Mayo PH. (2006). Achieving housestaff competence in emergency airway management using scenario based simulation training: comparison of attending vs housestaff trainers. Chest. 129(6): 1453-8. Schlinderwein M, von Wagner G, Kirst M, Rajewicz M, Karl F, Schochlin J, Bolz A. (2002). Mobile patient simulator for resuscitation training with automatic external defibrillators. Biomed Tech (Berl); 47 2:559-60. Weller JM. (2004). Simulation in undergraduate medical education: bridging the gap between theory and practice. Med Educ. 38(1): 32-8. Wik L. Thowsen J. Steen PA.(2001). An automated voice advisory manikin system for training in basic life support without an instructor. A novel approach to CPR training. Resuscitation. 50(2): 167-72.