Simulation in healthcare: journal of the Society for Simulation in Healthcare

Published by Lippincott, Williams & Wilkins
Online ISSN: 1559-2332
Publications
Article
Behavioral skills such as effective communication, teamwork, and leadership are critically important to successful outcomes in patient care, especially in resuscitation situations where correct decisions must be made rapidly. However, historically, these important skills have rarely been specifically addressed in learning programs directed at healthcare professionals. Not only have most healthcare professionals had little or no formal education and training in applying behavioral skills to their patient care activities but also many of those serving as instructors and content experts for training programs have few resources available that clearly illustrate what these skills are and how they may be used in the context of real clinical situations. This represents a serious shortcoming in the education and training of healthcare professionals and stands in distinct contrast to other industries.Aerospace, similar to other high-consequence industries, has a long history of the use of simulation to improve human performance and reduce risk: astronauts and the engineers in Mission Control spend hundreds of hours in simulated flight in preparation for every mission. The value of time spent in the simulator was clearly illustrated during the flight of Apollo 13, the third mission to land men on the moon. The Apollo 13 crew had to overcome a number of life-threatening technical and medical problems, and it was their simulation-based training that allowed them to display the teamwork, ingenuity, and determination needed to return to earth safely.The movie Apollo 13 depicts in a highly realistic manner the events that occurred during the flight, including the actions of the crew in space and those in Mission Control in Houston. Three scenes from this movie are described in this article; each serves as a useful example for healthcare professionals of the importance of simulation-based learning and the application of behavioral skills to successful resolution of crises. This article is meant to serve as a guide as to how this movie and other similar media may be used for facilitated group or independent learning, providing appropriate context and clear examples of key points to be discussed.
 
Article
Medical simulation takes advantage of contextual and experiential learning by allowing trainees to practice in realistic environments prior to actual patient care. Although proponents argue that patient simulation can fundamentally enhance both medical education and patient safety, large-scale experience with advanced simulation technologies is limited. To explore expert opinion on the topic, we convened a conference of educational leaders and simulation experts to provide recommendations for how this field should be directed on a broad scale to improve the training of future health professionals. This document summarizes the proceedings of that conference. We issued a request for applications to all U.S. and Canadian medical schools within the Association of American Medical Colleges (AAMC), seeking a diverse group of institutional teams committed to an in-depth exploration of the topic. Of 33 applications, nine medical schools were selected to participate. Once on site, eight working groups were formed, each comprised of representatives across sites and roles, including deans, clerkship and program directors, content experts, and trainees. We addressed four key topics, which are subsequently summarized for presentation in this report: 1) education (How can medical simulation contribute to the education of trainees?), 2) assessment (What is the role of simulation in evaluating trainees in the context of general competencies?), 3) research (How should we develop a research agenda to evaluate simulation?), and 4) implementation (How should simulation technologies be developed and managed within and across institutions?). Participants in the conference generally agreed that simulation offers a conducive environment for focused reflection and critical thought. Although there was consensus that medical simulation can provide a robust platform for performance assessment, most participants thought that the research basis for high-stakes assessment was still too immature for widespread implementation. Participants generally agreed that sufficiently powered research will require interinstitutional collaboration on uniform curricula and meaningful outcome tools, and that both biomedical and social science research paradigms will need to be applied to the questions at hand. Common barriers to medical simulation include both real and perceived lack of resources, poor understanding among faculty regarding the nature of the tools and techniques, and the inherent complexity of multidisciplinary collaboration. Medical simulation can and should be used to complement current methods of medical education. Educators should make thoughtful choices among simulation modalities to help trainees most effectively achieve learning objectives. Simulation researchers should prioritize the development and validation of clinical performance tools and other defined outcome measures on which meaningful large-scale research can be anchored. Finally, national collaboration should be encouraged and fostered by institutions and funding agencies.
 
Article
In November 2006, a Simulation Summit was convened in Chicago, IL by the Society for Simulation in Healthcare. The purpose of this gathering was to bring together stakeholders from the widest possible range of societies, organizations, and regulatory agencies with an interest in healthcare simulation. Thirty-three organizations were represented by over 50 participants. Through structured small and large group discussions, eight major themes emerged for the advancement of simulation into the mainstream of healthcare education. Four of these were unanimously agreed upon, and four were widely accepted by the group. This paper summarizes the results of this Summit including future plans to advance the integration of simulation into the mainstream of healthcare.
 
Article
The Society for Simulation in Healthcare convened the second Simulation Education Summit meeting in October 2007 in Chicago, Illinois. The purpose of the Summit was to bring together leaders of public, private, and government organizations, associations, and agencies involved in healthcare education for a focused discussion of standards for simulation-based applications. Sixty-eight participants representing 36 organizations discussed in structured small and large groups the criteria needed for various training and assessment applications using simulation. Although consensus was reached for many topics, there were also areas that required further thought and dialogue. This article is a summary of the results of these discussions along with a preliminary draft of a guideline for simulation-based education.
 
Article
: Anesthesiologists' cognitive resources such as their attention, knowledge, and strategies play an important role in the prevention and correction of critical events. In this paper, we examined anesthesiologists' responses to the anesthesia machine (AM) in the "off" position during a simulated emergent cesarean section scenario. : All simulations were videotaped which allowed for offline review. At the beginning of the scenario, the AM system switch was purposefully turned to the off/standby position. The responses of 14 anesthesia residents at the Veterans Affairs Palo Alto Health Care System and Stanford University Simulation Center for Crisis Management Training in Health Care (VASC) and 11 anesthesia residents at the Boston Center for Medical Simulation (CMS) were analyzed. : Nine subjects at VASC restored the AM system switch to the "on" position on their own, whereas five subjects required help from another clinician. The median response time (RT) for all 14 subjects was 149.5 seconds. At CMS, five subjects restored the AM system switch to the "on" position on their own (median RT = 207 seconds), whereas two subjects received help from another anesthesia resident. There were four cases where the AM system switch problem was not corrected. : Factors that could have contributed to subjects' difficulty in detecting and correcting the AM system switch included the unusual nature of the problem, the human factors design of the AM front panel and system switch, and inadequate training by the subjects. Improving the appearance of the AM's system switch and training of clinicians to recognize the location and functionality of the AM system switch could be useful in correcting such an event in a timely manner and reducing patient risk.
 
Caucasian adult male mandibles 
VM1Scaled in Blue color superimposed over VM2 in Grey color 
(VM1Scaled ,VM2) Vertices distance map 
Article
Simulation and modeling represent promising tools for several application domains from engineering to forensic science and medicine. Advances in 3D imaging technology convey paradigms such as augmented reality (AR) and mixed reality inside promising simulation tools for the training industry. Motivated by the requirement for superimposing anatomically correct 3D models on a human patient simulator (HPS) and visualizing them in an AR environment, the purpose of this research effort was to develop and validate a method for scaling a source human mandible to a target human mandible within a 2 mm root mean square (RMS) error. Results show that, given a distance between 2 same landmarks on 2 different mandibles, a relative scaling factor may be computed. Using this scaling factor, results show that a 3D virtual mandible model can be made morphometrically equivalent to a real target-specific mandible within a 1.30 mm RMS error. The virtual mandible may be further used as a reference target for registering other anatomic models, such as the lungs, on the HPS. Such registration will be made possible by physical constraints among the mandible and the spinal column in the horizontal normal rest position.
 
Article
Summary statement: In September 2011, the Association of American Medical Colleges released the results of a survey conducted in 2010 on simulation activities at its member medical schools and teaching hospitals. In this commentary, we offer a synthesis of data and conclude that (1) simulation is used broadly at Association of American Medical Colleges member institutions, for many types of learners, including other health care professionals; (2) it addresses core training competencies and has many educational purposes; (3) its use in learner assessment is more prevalent at medical schools but is still significant at teaching hospitals; and (4) it requires a considerable investment of money, space, personnel, and time. These data confirm general perceptions about the state of simulation in North America for physician training. Future endeavors should include a more granular examination of how simulation is integrated into curricula, a similar survey of other health care-related institutions and professions, and a periodic assessment to characterize trends over time.
 
Article
Crisis resource management (CRM) skills are a set of nonmedical skills required to manage medical emergencies. There is currently no gold standard for evaluation of CRM performance. A prior study examined the use of a global rating scale (GRS) to evaluate CRM performance. This current study compared the use of a GRS and a checklist as formal rating instruments to evaluate CRM performance during simulated emergencies. First-year and third-year residents participated in two simulator scenarios each. Three raters then evaluated resident performance in CRM using edited video recordings using both a GRS and a checklist. The Ottawa GRS provides a seven-point anchored ordinal scale for performance in five categories of CRM, and an overall performance score. The Ottawa CRM checklist provides 12 items in the five categories of CRM, with a maximum cumulative score of 30 points. Construct validity was measured on the basis of content validity, response process, internal structure, and response to other variables. T-test analysis of Ottawa GRS scores was conducted to examine response to the variable of level of training. Intraclass correlation coefficient (ICC) scores were used to measure inter-rater reliability for both scenarios. Thirty-two first-year and 28 third-year residents participated in the study. Third-year residents produced higher mean scores for overall CRM performance than first-year residents (P < 0.05), and in all individual categories within the Ottawa GRS (P < 0.05) and the Ottawa CRM checklist (P < 0.05). This difference was noted for both scenarios and for each individual rater (P < 0.05). No statistically significant difference in resident scores was observed between scenarios for both instruments. ICC scores of 0.59 and 0.61 were obtained for Scenarios 1 and 2 with the Ottawa GRS, whereas ICC scores of 0.63 and 0.55 were obtained with the Ottawa CRM checklist. Users indicated a strong preference for the Ottawa GRS given ease of scoring, presence of an overall score, and the potential for formative evaluation. Construct validity seems to be present when using both the Ottawa GRS and CRM checklist to evaluate CRM performance during simulated emergencies. Data also indicate the presence of moderate inter-rater reliability when using both the Ottawa GRS and CRM checklist.
 
Article
The objective is to develop a low-fidelity total abdominal hysterectomy (TAH) model for resident training with the purpose to improve residents' knowledge of anatomy, instruments, instrument handling, suture selection, and steps of a TAH. A TAH model was created using products purchased from a crafts store. Obstetrics and gynecology residents (second-year residents and fourth-year residents) were subjected to a lecture followed by a simulated TAH. Before and after the course, subjects were given a survey to assess their confidence regarding the different surgical aspects of the TAH. Confidence was assessed regarding knowledge of anatomy, instruments, instrument handling, suture selection, incision site, steps of the TAH, and global confidence. Statistical analysis was performed using nonparametric tests. A P < 0.05 was considered significant. A low-fidelity TAH model was created. Eight second-year residents and seven fourth-year residents were studied. As expected, second-year residents had a lower median number of hysterectomies performed as primary surgeon when compared with fourth-year residents [0.5 (0.0-1.75) vs. 51.0 (50.0-53.0); P < 0.05]. Despite this difference, after having undergone the course, both resident classes demonstrated either statistical trends or significantly increased surgical confidence in all areas studied. Our novel, low-fidelity TAH simulation model and course improves obstetrics and gynecology residents' confidence in surgical skills and knowledge, particularly for those with less surgical experience. The total cost to make approximately 18 models was US $60.00.
 
Article
Prostate carcinoma (and other prostate irregularities and abnormalities) is detected in part via the digital rectal examination. Training clinicians to use particular palpation techniques may be one way to improve the rates of detection. In an experiment of 34 participants with clinical backgrounds, we used a custom-built simulator to determine whether certain finger palpation techniques improved one's ability to detect abnormalities smaller in size and dispersed as multiples over a volume. The intent was to test abnormality cases of clinical relevance near the limits of size perceptibility (ie, 5-mm diameter). The simulator can present abnormalities in various configurations and record finger movement. To characterize finger movement, four palpation techniques were quantitatively defined (global finger movement, local finger movement, average intentional finger pressure, and dominant intentional finger frequency) to represent the qualitative definitions of other researchers. Participants who used more thorough patterns of global finger movement (V and L) ensured that the entire prostate was searched and detected more abnormalities. A higher magnitude of finger pressure was associated with the detection of smaller abnormalities. The local finger movement of firm pressure with varying intensities was most indicative of success and was required to identify the smallest (5-mm diameter) abnormality. When participants used firm pressure with varying intensities, their dominant intentional finger frequency was about 6 Hz. The use of certain palpation techniques does enable the detection of smaller and more numerous abnormalities, and we seek to abstract these techniques into a systematic protocol for use in the clinic.
 
Article
Cutaneous abscesses are common, and emergency physicians in training must develop competency with abscess identification and management through incision and drainage. Although simulation models can enable proficiency in such skills, current abscess models described in the literature suffer from limitations. The author presents a novel abscess management training simulator evaluated by physicians. An artificial abscess wall tunneled near the surface of a chicken breast is injected with mock purulent material to create the simulator. Twenty physicians familiar with abscess identification and management assessed the model. The educational value of the model and its sonographic fidelity were evaluated via closed-ended questions and open-ended feedback. All 20 physician evaluators agreed that an abscess simulator model would be a useful teaching tool and that this particular abscess model would be a useful teaching tool. The evaluators' found the model to realistically simulate a real abscess, but cited the lack of purulent loculations as a potential limitation. When responding to the statement "the ultrasound image of the simulated abscess appears realistic," all physicians either "strongly agreed" or "agreed" with the statement (n = 20). This new simulation model may be an effective tool to teach skin abscess management. Physicians who evaluated the simulated abscess found that it replicates the classic palpable fluctuance and ultrasound findings of an actual abscess, and it can be surgically incised and drained in a similar fashion. Although physicians agreed that this model would be useful, future studies may validate this task trainer as an effective teaching tool.
 
Article
Patient simulators incorporate a range of technical features. An understanding of which features are most valuable and which may be less so is important for simulator design and utilization. In this study, we attempted to answer the question of whether or not certain simulator features are perceived by learners as more useful than others in achieving specified educational objectives. The subjects were third and fourth year medical students participating in an Emergency Medicine Simulation Workshop (n = 97). Following the Workshop, subjects rated each of 13 simulator features on a 5-point scale from distracting to extremely useful in achieving specified educational objectives; and then identified the most and least useful features. There were significant differences between the scores of the most highly rated features (vital sign display, interactive voice, chest rise, and palpable pulse), and those of the features with the lowest ratings (abnormal breath sounds, prerecorded voice, IV arm, and heart tones) (4.75 vs. 3.93, P < 0.0001). Three features (heart tones, abnormal breath sounds, and prerecorded voice) were rated by more than one third of the students as distracting, not useful, or uncertain if useful. On the ranking scale, highly rated features tended to be identified as most useful, and those with the lowest ratings were more often ranked as least useful. There was a statistically significant (P < 0.0001) correlation between rating and rankings. There are significant differences in the perceived usefulness of patient simulator features. This has implications both for simulator design and for simulator-based education.
 
Article
Simulation-based education is indispensable in preparing healthcare providers for patient care. Simulation centers and programs that serve as a critical platform for promoting patient safety and high-quality training depend on multiple requirements for success: diversified and sustainable financing, technical personnel with a long-term commitment to simulation education, simulation and information technology infrastructure designed to match priority training needs, and resources for curricular development, instruction, faculty development, and research. An additional requirement not widely discussed in the literature is the recruitment and retention of faculty who serve as simulation educators, which is the focus of this report.
 
Article
To explore whether a simulated critical care encounter can accelerate basic science learning among preclinical medical students. Using a high-fidelity patient simulator, we "brought to life" a paper case of a myocardial infarction among a convenience sample of first-year medical students (n=22 [intervention]). Students discussed the case as part of a routine tutorial session, and then managed the case in the simulator laboratory. Using an identical six-item test of cardiac physiology, students were evaluated immediately after the simulator session and at 1 year (n=15). Performance was compared with controls (case discussion but no simulator session) at both baseline (n=37) and 1 year (n=48). Performance among simulator-exposed students was significantly enhanced on immediate testing (mean score 4.0 [control], 4.7 [intervention], P = .005). Gains among the simulator cohort were maintained at 1 year (mean score 4.1 [control], 4.7 [intervention], P = .045). Multivariable analysis confirmed that the intervention was a significant determinant of performance across time (P = .001). Compared with controls in this pilot study, an additional simulation exercise improved immediate performance on a short written test of cardiovascular physiology. Enhanced performance was again seen at 1 year, raising the possibility that the extra teaching session produced accelerated and sustained learning compared with the routine teaching method. Given the preliminary nature of this investigation, further study is required to distinguish transient from lasting effects of simulation versus alternative teaching approaches in the basic medical sciences.
 
Article
Mixed-reality (MR) procedural simulators combine virtual and physical components and visualization software that can be used for debriefing and offer an alternative to learn subclavian central venous access (SCVA). We present a SCVA MR simulator, a part-task trainer, which can assist in the training of medical personnel. Sixty-five participants were involved in the following: (1) a simulation trial 1; (2) a teaching intervention followed by trial 2 (with the simulator's visualization software); and (3) trial 3, a final simulation assessment. The main test parameters were time to complete SCVA and the SCVA score, a composite of efficiency and safety metrics generated by the simulator's scoring algorithm. Residents and faculty completed questionnaires presimulation and postsimulation that assessed their confidence in obtaining access and learner satisfaction questions, for example, realism of the simulator. The average SCVA score was improved by 24.5 (n = 65). Repeated-measures analysis of variance showed significant reductions in average time (F = 31.94, P < 0.0001), number of attempts (F = 10.56, P < 0.0001), and score (F = 18.59, P < 0.0001). After the teaching intervention and practice with the MR simulator, the results no longer showed a difference in performance between the faculty and residents. On a 5-point scale (5 = strongly agree), participants agreed that the SCVA simulator was realistic (M = 4.3) and strongly agreed that it should be used as an educational tool (M = 4.9). An SCVA mixed simulator offers a realistic representation of subclavian central venous access and offers new debriefing capabilities.
 
Article
Simulation training for invasive procedures may improve patient safety by enabling efficient training. This study is a meta-analysis with rigorous inclusion and exclusion criteria designed to assess the real patient procedural success of simulation training for central venous access. Published randomized controlled trials and prospective 2-group cohort studies that used simulation for the training of procedures involving central venous access were identified. The quality of each study was assessed. The primary outcome was the proportion of trainees who demonstrated the ability to successfully complete the procedure. Secondary outcomes included the mean number of attempts to procedural success and periprocedural adverse events. Proportions were compared between groups using risk ratios (RRs), whereas continuous variables were compared using weighted mean differences. Random-effects analysis was used to determine pooled effect sizes. We identified 550 studies, of which 5 (3 randomized controlled trials, 2 prospective 2-group cohort studies) studies of central venous catheter (CVC) insertion were included in the meta-analysis, composed of 407 medical trainees. The simulation group had a significantly larger proportion of trainees who successfully placed CVCs (RR, 1.09; 95% confidence interval [CI], 1.03-1.16, P < 0.01). In addition, the simulation group had significantly fewer mean attempts to CVC insertion (weighted mean difference, -1.42; 95% CI, -2.34 to -0.49, P < 0.01). There was no significant difference in the rate of adverse events between the groups (RR, 0.50; 95% CI, 0.19-1.29; P = 0.15). Training programs should consider adopting simulation training for CVC insertion to improve the real patient procedural success of trainees.
 
Article
We propose an intraosseous (IO) procedure scale for evaluating the insertion process during simulation. A 12-item scale for assessing the performance of IO insertion into the proximal tibia reproduces all the steps of a manual procedure. The performance of 31 emergency physicians was evaluated with this scale on a mannequin simulating a decompensated shock in a 6-month-old infant.Our IO procedure scale was reliable, with a very high interobserver reproducibility. The application of this scale to procedures yielded higher scores for successful than for unsuccessful procedures (P < 10), a 93.5% success rate, and a mean placement time of 2 minutes 23 seconds. Although designed for a manual insertion of an IO needle during simulation, this scale may be also suitable for use in clinical settings.
 
Article
The Accreditation for Graduate Medical Education has developed a new process of accreditation, the Next Accreditation System (NAS), which focuses on outcomes. A key component of the NAS is specialty milestones-specific behavior, attributes, or outcomes within the general competency domains. Milestones will mark a level of proficiency of a resident within a competency domain. Each specialty has developed its own set of milestones, with semiannual reporting to begin July 2013, for 7 specialties, and the rest in July 2014.Milestone assessment must be based on objective data. Each specialty will determine optimal methods of measuring milestones, based on ease, cost, validity, and reliability. The simulation community has focused many graduate medical education efforts at training and formative assessment. Milestone assessment represents an opportunity for simulation modalities to offer summative assessment of milestone proficiencies, adding to the potential methods that residency programs will likely use or adapt. This article discusses the NAS, milestone assessment, and the opportunity to the simulation community to become involved in this next stage of graduate medical education assessment.
 
Article
Purpose: The Accreditation Council for Graduate Medical Education (ACGME) guidelines recommend that residents perform 6 cardiac pacing attempts during residency training, while making no distinction between transcutaneous pacing (TCP) or transvenous pacing (TVP). This study seeks to enhance and validate emergency medicine residency curricula by assessing and measuring the minimum number of performances for TCP and TVP through simulation for procedural competency. Methods: In 2009-2010, 36 residents were invited to the simulation laboratory to participate in individual procedural training sessions. The residents each rotated through the 2 following partial-task training stations staffed by faculty members: (1) TVP and (2) TCP. Using the process of deliberate practice, the procedures were repeated until the faculty members had determined procedural competency defined as 2 completions without error via a preset checklist. Results: Residents required a mean (SD) of 3.11 (0.56) attempts and a median of 3 attempts to successfully perform TCP and a mean (SD) of 5.25 (0.94) attempts and a median of 6 attempts to successfully perform TVP. Learners required a mean (SD) total number of 8.39 (1.09) attempts and a median of 9 attempts to achieve competency at cardiac pacing. No resident required more than 5 attempts to achieve competency in TCP; no resident required more than 6 attempts to achieve competency in TVP. Conclusions: When measuring TVP alone, the number of attempts to achieve competency are comparable with that of the ACGME guidelines. When accounting for both TCP and TVP, the number of attempts required to achieve competency is greater than those delineated by the ACGME guidelines. The results of this trial warrant continuation and reproduction on a larger scale to revisit the ACGME guidelines.
 
Article
The Effective Management of Anesthetic Crises (EMAC) course is a joint initiative between the Australian and New Zealand College of Anesthetists (ANZCA) and simulation centers. This standardized 2.5-day course has become an integral component of training for Fellowship of ANZCA and as such is an innovative development on the global anesthesia scene.Since its inception in 2002, over 600 anesthetists, with equal numbers of specialists and trainees, have attended EMAC throughout Australia, New Zealand, and Hong Kong. Course evaluations from 499 anesthetists and a follow-up survey showed strong support for the course and its relevance to clinical practice. The course is perceived by participants as changing their practice and improving their management of anesthetic crises.Exposure to the concepts of effective crisis management is now widespread in the anesthetic community in the region and should contribute to improved patient safety.
 
Article
: It is not known whether a Standardized Patient's (SP's) performing arts background could affect his or her accuracy in recording candidate performance on a high-stakes clinical skills examination, such as the Comprehensive Osteopathic Medical Licensing Examination Level 2 Performance Evaluation. The purpose of this study is to investigate the differences in recording accuracy of history and physical checklist items between SPs who identify themselves as performing artists and SPs with no performance arts experience. : Forty SPs identified themselves as being performing artists or nonperforming artists. A sample of SP live examination ratings were compared with a second set of ratings obtained after video review (N = 1972 SP encounters) over 40 cases from the 2008-2009 testing cycle. Differences in SP checklist recording accuracy were tested as a function of performing arts experience. : Mean overall agreement rates, both uncorrected and corrected for chance agreement, were very high (0.94 and 0.79, respectively, at the overall examination level). There was no statistically significant difference between the two groups with respect to any of the mean accuracy measures: history taking (z = -0.422, P = 0.678), physical examination (z = -1.453, P = 0.072), and overall data gathering (z = -0.812, P = 0.417) checklist items. : Results suggest that SPs with or without a performing arts background complete history taking and physical examination checklist items with high levels of precision. Therefore, SPs with and without performing arts experience can be recruited for high-stakes SP-based clinical skills examinations without sacrificing examination integrity or scoring accuracy.
 
Article
Team training in healthcare is usually evaluated by observers who either score trainees' behaviors, social skills, and cognitive skills during simulation or measure changes in the clinical state of a mannequin. Both methods have shortcomings that limit their usefulness. We propose Brunswik's probabilistic functionalism and the Accuracy Score (AS), a measure emerging from judgment analysis, as elements of a complementary approach that could increase the objectivity of team training evaluation. We report an initial investigation. Three groups of neonatal clinicians participated in a resuscitation experiment involving three different training interventions. During the experiment, at various phases, the participants were required to assign an Apgar score to a mannequin. The AS was used to test how accurately the clinicians assigned Apgar scores to the mannequin across different levels of task demand, training content, and training delivery method. The AS was lower when task demand increased (P < 0.01). The AS was higher after teamwork training than after clinical training (P < 0.05) and better after hands-on teamwork training than after lecture-based teamwork training (P < 0.05). Because it is simple and objective, the AS may complement existing measures for team training evaluation. Future studies are required in which the AS is tested with a larger number of trainees, in longitudinal experiments, across different training areas, and is compared with previously validated team performance measures.
 
Article
The Apgar score is used to describe the clinical condition of newborns. However, clinicians show low reliability when assigning Apgar scores to video recordings of actual neonatal resuscitations. Simulators provide a controlled environment for recreating and recording resuscitations. Clinicians assigned Apgar scores to such recordings to test the representativeness of simulator and recordings. Study design was guided by Brunswik's probabilistic functionalism. Judgment analysis methods were used to design 51 recordings of neonatal resuscitation scenarios, simulated with SimNewB (Laerdal, Stavanger, Norway). A step-by-step explanation of the design, preparation, and testing of the recordings is provided. Recorded Apgar scores, calculated from the presentation of clinical signs, were compared against the designed scores. Working independently and without feedback, three experts assigned Apgar scores to confirm that the recordings could be interpreted as intended. Seventeen neonatal resuscitation clinicians scored the recordings in a separate experiment. Correlations between Apgar scores assigned by the 20 viewers (experts plus clinicians) and recorded Apgar scores were high (0.78-0.91) and significant (P < 0.01). Fourteen of the 20 viewers scored the recordings without significant bias. Correlations between viewers' scores and scores of individualized linear models calculated for each viewer were high (0.79-0.97) and significant (P < 0.01), indicating systematic judgments. SimNewB provided a realistic presentation of clinical conditions that was preserved in the recordings. Clinicians could interpret clinical conditions systematically and accurately without feedback or detailed instructions. These methods are applicable to future research about accuracy of clinical assessments in actual and simulated environments.
 
Article
The aim of this study was to determine the number of ultrasound-guided (USG) central venous catheterization (CVC) of the internal jugular vein (IJV) residents had to perform, after a simulation-based training program, to achieve optimal clinical outcomes. We conducted a single-center, prospective, observational study in the medical intensive care unit of a university-affiliated teaching hospital. Residents participated in a formal training program, consisting of a simulation-based workshop and 5 supervised USG CVC insertions on patients. Subsequent USG CVC of the IJV performed by residents during their rotation were assessed. Data on the overall success (OS), first pass success (FP) and mechanical complication (MC) rates were serially collected over 2 years, spanning 4 cohorts of residents. Thirty-two residents performed a total of 337 USG CVC of the IJV. Residents had previously performed an average of 9 CVC via the landmark technique. None had performed USG CVC before. Results showed that residents improved in their OS, FP, and MC rates as they performed more USG CVC. Residents needed to perform 7 USG CVCs to achieve optimal clinical outcomes of high OS and FP as well as low MC rates. There was a significant improvement in OS, FP, and MC rates for the eighth and subsequent USG CVCs compared with the first 7 USG CVCs (82% vs. 99% [P < 0.001], 70% vs. 92% [P < 0.001] and 11% vs. 0%, respectively). After a formal training program consisting of a simulation-based workshop and 5 supervised USG CVCs on critically ill adults, residents were able to achieve optimal clinical outcomes after performing 7 procedures.
 
Article
A virtual reality (VR) surgical simulator (EyeSi ophthalmosurgical simulator: VRMagic, Mannheim, Germany) was evaluated as a part-task training platform for differentiating and developing basic ophthalmic microsurgical skills. Surgical novice performance (residents, interns, and nonmicrosurgical ophthalmic staff) was compared with surgical expert performance (practicing ophthalmic microsurgeons) on a basic navigational microdexterity module provided with the EyeSi simulator. Expert surgeons showed a greater initial facility with all microsurgical tasks. With repeated practice, novice surgeons showed sequential improvement in all performance scores, approaching but not equaling expert performance. VR simulator performance can be used as a gated, quantifiable performance goal to expert-level benchmarks. The EyeSi is a valid part-task training platform that may help develop novice surgeon dexterity to expert surgeon levels.
 
Article
Educators often simplify complex tasks by setting learning objectives that focus trainees on isolated skills rather than the holistic task. We designed 2 sets of learning objectives for intravenous catheterization using goal setting theory. We hypothesized that setting holistic goals related to technical, cognitive, and communication skills would result in superior holistic performance, whereas setting isolated goals related to technical skills would result in superior technical performance. We randomly assigned practicing health care professionals to set holistic (n = 14) or isolated (n = 15) goals. All watched an instructional video and studied a list of 9 goals specific to their group. Participants practiced independently in a hybrid simulation (standardized patient combined with an arm simulator). The first and the last practice trials were videotaped for analysis. One-week later, participants completed a transfer test in another hybrid simulation scenario. Blinded experts evaluated performance on all 3 trials using the Direct Observation of Procedural Skills tool. The holistic group scored higher than the isolated group on the holistic Direct Observation of Procedural Skills score for all 3 trials [mean (SD), 45.0 (9.16) vs. 38.4 (9.17); P = 0.01]. The isolated group did not perform better than the holistic group on the technical skills score [10.3 (2.73) vs. 11.6 (3.01); P = 0.11]. Our results suggest that asking learners to set holistic goals did not interfere with their attaining competent holistic and technical skills during hybrid simulation training. This exploratory trial provides preliminary evidence for how to consider integrating hybrid simulation into medical curricula and for the design of learning goals in simulation-based education.
 
Article
Pediatric emergencies require effective teamwork. These skills are developed and demonstrated in actual emergencies and in simulated environments, including simulation centers (in center) and the real care environment (in situ). Our aims were to compare teamwork performance across these settings and to identify perceived educational strengths and weaknesses between simulated settings. We hypothesized that teamwork performance in actual emergencies and in situ simulations would be higher than for in-center simulations. A retrospective, video-based assessment of teamwork was performed in an academic, pediatric level 1 trauma center, using the Team Emergency Assessment Measure (TEAM) tool (range, 0-44) among emergency department providers (physicians, nurses, respiratory therapists, paramedics, patient care assistants, and pharmacists). A survey-based, cross-sectional assessment was conducted to determine provider perceptions regarding simulation training. One hundred thirty-two videos, 44 from each setting, were reviewed. Mean total TEAM scores were similar and high in all settings (31.2 actual, 31.1 in situ, and 32.3 in-center, P = 0.39). Of 236 providers, 154 (65%) responded to the survey. For teamwork training, in situ simulation was considered more realistic (59% vs. 10%) and more effective (45% vs. 15%) than in-center simulation. In a video-based study in an academic pediatric institution, ratings of teamwork were relatively high among actual resuscitations and 2 simulation settings, substantiating the influence of simulation-based training on instilling a culture of communication and teamwork. On the basis of survey results, providers favored the in situ setting for teamwork training and suggested an expansion of our existing in situ program.
 
Article
Organizational behavior and management fields have long realized the importance of teamwork and team-building skills, but only recently has health care training focused on these critical elements. Communication styles and strategies are a common focus of team training but have not yet been consistently applied to medicine. We sought to determine whether such communication strategies, specifically "advocacy" and "inquiry," were used de novo by medical professionals in a simulation-based teamwork and crisis resource management course. Explicit expression of a jointly managed clinical plan between providers, a strategy shown to improve patient safety, was also evaluated. Forty-four of 54 videotaped performances of an ongoing team-building skills course were viewed and analyzed for presence of advocacy and/or inquiry that related to information or a plan; inclusion criteria were participation of a nonconfederate obstetrician and an anesthesiologist. Verbal statement of a jointly managed clinical plan was also recorded. Anesthesiologists advocated information in 100% of cases and advocated their plans in 93% of cases but inquired information in 30% of cases and inquired about the obstetricians' plans in 11% of cases. Obstetricians advocated information in 73% of cases, advocated their plans in 73% of cases, inquired information in 75% of cases, and inquired about the anesthesiologists' plans in 59% of cases. An explicitly stated joint team plan was formed in 45% of cases. Anesthesiologists advocated more frequently than obstetricians, while obstetricians inquired and advocated in more balanced proportions. However, fewer than half of the teams explicitly agreed on a joint plan. Increasing awareness of communication styles, and possibly incorporating these skills into medical training, may help teams arrive more efficiently at jointly managed clinical plans in crisis situations.
 
Article
Prenatal counseling at the threshold of viability is a challenging yet critically important activity, and care guidelines differ across cultures. Studying how this task is performed in the actual clinical environment is extremely difficult. In this pilot study, we used simulation as a methodology with 2 aims as follows: first, to explore the use of simulation incorporating a standardized pregnant patient as an investigative methodology and, second, to determine similarities and differences in content and style of prenatal counseling between American and Dutch neonatologists. We compared counseling practice between 11 American and 11 Dutch neonatologists, using a simulation-based investigative methodology. All subjects performed prenatal counseling with a simulated pregnant patient carrying a fetus at the limits of viability. The following elements of scenario design were standardized across all scenarios: layout of the physical environment, details of the maternal and fetal histories, questions and responses of the standardized pregnant patient, and the time allowed for consultation. American subjects typically presented several treatment options without bias, whereas Dutch subjects were more likely to explicitly advise a specific course of treatment (emphasis on partial life support). American subjects offered comfort care more frequently than the Dutch subjects and also discussed options for maximal life support more often than their Dutch colleagues. Simulation is a useful research methodology for studying activities difficult to assess in the actual clinical environment such as prenatal counseling at the limits of viability. Dutch subjects were more directive in their approach than their American counterparts, offering fewer options for care and advocating for less invasive interventions. American subjects were more likely to offer a wider range of therapeutic options without providing a recommendation for any specific option.
 
Article
Summary statement: Among the most powerful tools available to simulation instructors is a confederate. Although technical and logical realism is dictated by the simulation platform and setting, the quality of role playing by confederates strongly determines psychological or emotional fidelity of simulation. The highest level of realism, however, is achieved when the confederates are properly trained. Theater and acting methodology can provide simulation educators a framework from which to establish an acting convention specific to the discipline of healthcare simulation. This report attempts to examine simulation through the lens of theater arts and represents an opinion on acting in healthcare simulation for both simulation educators and confederates. It aims to refine the practice of simulation by embracing the lessons of the theater community. Although the application of these approaches in healthcare education has been described in the literature, a systematic way of organizing, publicizing, or documenting the acting within healthcare simulation has never been completed. Therefore, we attempt, for the first time, to take on this challenge and create a resource, which infuses theater arts into the practice of healthcare simulation.
 
Article
In healthcare, professionals usually function in a time-constrained paradigm because of the nature of care delivery functions and the acute patient populations usually in need of emergent and urgent care. This leaves little, if no time for team reflection, or team processing as a collaborative action. Simulation can be used to create a safe space as a structure for recognition and innovation to continue to develop a culture of safety for healthcare delivery and patient care. To create and develop a safe space, three qualitative modified action research institutional review board-approved studies were developed using simulation to explore team communication as an unfolding in the acute care environment of the operating room. An action heuristic was used for data collection by capturing the participants' narratives in the form of collaborative recall and reflection to standardize task, process, and language. During the qualitative simulations, the team participants identified and changed multiple tasks, process, and language items. The simulations contributed to positive changes for task and efficiencies, team interactions, and overall functionality of the team. The studies demonstrated that simulation can be used in healthcare to define safe spaces to practice, reflect, and develop collaborative relationships, which contribute to the realization of a culture of safety.
 
Article
Summary statement: Role-play is a method of simulation used commonly to teach communication skills. Role-play methods can be enhanced by techniques that are not widely used in medical teaching, including warm-ups, role-creation, doubling, and role reversal. The purposes of these techniques are to prepare learners to take on the role of others in a role-play; to develop an insight into unspoken attitudes, thoughts, and feelings, which often determine the behavior of others; and to enhance communication skills through the participation of learners in enactments of communication challenges generated by them. In this article, we describe a hypothetical teaching session in which an instructor applies each of these techniques in teaching medical students how to break bad news using a method called SPIKES [Setting, Perception, Invitation, Knowledge, Emotions, Strategy, and Summary]. We illustrate how these techniques track contemporary adult learning theory through a learner-centered, case-based, experiential approach to selecting challenging scenarios in giving bad news, by attending to underlying emotion and by using reflection to anchor new learning.
 
Article
Summary statement: Postsimulation debriefing is a critical component of effective learning in simulation-based health care education. Numerous formats in which to conduct the debriefing have been proposed. In this report, we describe the adaptation the US Army's After-Action Review (AAR) debriefing format for postsimulation debriefing in health care. The Army's AAR format is based on sound educational theory and has been used with great success in the US Army and civilian organizations for decades. Debriefing using the health care simulation AAR process requires planning, preparation, and follow-up. Conducting a postsimulation debriefing using the health care simulation AAR debriefing format includes 7 sequential steps as follows: (1) define the rules of the debriefing, (2) explain the learning objectives of the simulation, (3) benchmark performance, (4) review what was supposed to happen during the simulation, (5) identify what actually happened, (6) examine why events occurred the way they did, and (7) formalize learning by reviewing with the group what went well, what did not go well and what they would do differently if faced with a similar situation in real life. We feel that the use of the health care simulation AAR debriefing format provides a structured and supported method to conduct an effective postsimulation debriefing, with a focus on the learning objectives and reliance on preidentified performance standards.
 
Article
We describe our more than 10 years' experience working with actors and provide a "how-to" guide to recruiting, auditioning, hiring, training, and mentoring actors for work as simulated patients in simulation programs. We contend that trained actors add great realism, richness, and depth to simulation-based training programs. The actors experience satisfaction from their contributions, and their skill and improvisational talent allow programs to offer ethical and relational training, customized to a wide range of practitioners and adapted across a variety of health care conversations. Such learning opportunities can directly address Accreditation Council for Graduate Medical Education core competencies in preparing capable, confident, and empathic health care practitioners.
 
Article
Patient satisfaction is an important healthcare outcome and communication with clinical staff is an important determinant. Simulation could identify problems and inform corrective action to improve patient experience. One hundred eight randomly selected maternity professionals in 18 teams were videoed managing a patient-actor with a simulated emergency. The trained patient-actor assessed the quality of staff-patient interaction. Clinicians scored teams for their teamwork skills and behaviors. There was significant variation in staff-patient interaction, with some teams not having exchanged a single word and others striving to interact with the patient-actor in the heat of the emergency. There was significant correlation between patient-actor perceptions of communication, respect, and safety and individual and team behaviors: number, duration, and content of communication episodes, as well as generic teamwork skills and teamwork behaviors. The patient-actor perception of safety was better when the content of the communication episodes with them included certain items of information, but most teams failed to communicate these to the patient-actor. Some aspects of staff-patient interaction and teamwork during management of a simulated emergency varied significantly and were often inadequate in this study, indicating a need for better training of individuals and teams.
 
Article
When navigating a needle from skin to epidural space, a skilled clinician maintains a mental model of the anatomy and uses the various forms of haptic and visual feedback to track the location of the needle tip. Simulating the procedure requires an actuator that can produce the feel of tissue layers even as the needle direction changes from the ideal path. A new actuator and algorithm architecture simulate forces associated with passing a needle through varying tissue layers. The actuator uses a set of cables to suspend a needle holder. The cables are wound onto spools controlled by brushless motors. An electromagnetic tracker is used to monitor the position of the needle tip. Novice and expert clinicians simulated epidural insertion with the simulator. Preliminary depth-time curves show that the user responds to changes in tissue properties as the needle is advanced. Some discrepancy in clinician response indicates that the feel of the simulator is sensitive to technique, thus perfect tissue property simulation has not been achieved. The new simulator is able to approximately reproduce properties of complex multilayer tissue structures, including fine-scale texture. Methods for improving fidelity of the simulation are identified.
 
Article
In medicine, standard setting methodologies have been developed for both selected-response and performance-based assessments. For simulation-based tasks, research efforts have been directed primarily at assessments that incorporate standardized patients. Mannequin-based evaluations often demand complex, time-sensitive, hierarchically ordered, sequential actions that are difficult to evaluate and score. Moreover, collecting reliable proficiency judgments, necessary to estimate meaningful cut points, can be challenging. The purpose of this investigation was to explore whether expert judgments obtained using an examinee-centered standard setting method that was previously validated for standardized patient-based assessments could be used to set defensible standards for acute-care, mannequin-based scenarios. Nineteen physicians were recruited to serve as panelists. For each of 12 simulation scenarios, between 8 and 10 performance samples (audio-video recordings), covering the expected ability continuum, were chosen for review. The performance samples were selected from a previously administered evaluation of postgraduate trainees. Based on a consensus definition of readiness to enter unsupervised practice, the panelists made independent judgments of each performance. For each scenario, the association between the panelists' judgments and the assessment scores was summarized and used to estimate a scenario-specific cut score. For 9 of the scenarios, there was at least a moderately strong relationship between the aggregate panelists' rating and the performance scores, thus allowing for estimation of meaningful numeric standards. For the other 3 scenarios, the aggregate decision rules used by the panelists did not correspond with the achievement measures. For scenarios independently rated by split panels, the estimated cut scores were similar. An examinee-centered approach, using aggregate expert judgments of audio-video performances, was suitable for setting standards on most acute-care, mannequin-based scenarios. It is necessary, however, to have valid scores for the chosen scenarios and to sample performances across the ability spectrum.
 
Article
Patient simulators provide an opportunity for teams to rehearse scenarios where a rapid coordinated response is essential for improving the clinical outcome. Treatment of acute ischemic stroke is time dependent and intravenous thrombolysis must be administered within hours of symptom onset. This requires a complicated assessment process often led in its initial stages by emergency department staff. We describe a new single-day training event that uses simulated scenarios to demonstrate stroke recognition and an intravenous thrombolysis protocol. Stroke and TIA Assessment Training (STAT) uses video and audio clips from real patients in conjunction with a patient simulator to create interactive scenarios for emergency department staff. Between May 2009 and April 2011, 779 clinical staff in the United Kingdom attended a STAT course. Data from the first year of STAT showed that learner self-confidence for stroke assessment increased significantly. The use of the simulator was highly valued. A patient simulator can be successfully combined with patient video material to demonstrate neurologic features in the context of acute stroke assessment.
 
Article
There is a lack of comparative data with simulation-based learning (SBL) and other types of learning. The objective of the study was to determine whether high-fidelity simulation is superior to problem-based learning (PBL) for training pharmacy students in an acute care elective. Twenty-nine pharmacy students enrolled in the Acute Care Pharmacotherapy Simulation course over 2 years voluntarily participated in this randomized, crossover study. Students were randomized to group 1 or 2. The SBL group consisted of students in group 1 who had SBL during study week 1 and group 2 students who had SBL in week 2. The PBL group consisted of students in group 1 who had PBL cases during study week 2 and group 2 students who had PBL cases in week 1. The topics covered were management of dysrhythmias (week 1) and heart failure (week 2). The SBL group significantly improved compared with the PBL on postquiz scores. The SBL group performed at least 15% better in the clinical assessment (P = 0.013). Students in the SBL group performed significantly better in their critical thinking skills for problem list, pharmacotherapy plan, and monitoring plan. Learning was enhanced with the use of SBL compared with PBL.
 
Top-cited authors
David Gaba
  • VA Palo Alto Health Care System
Jenny W Rudolph
  • Massachusetts General Hospital
Robert Simon
  • Harvard Medical School, Massachusetts General Hospital
Adam Cheng
  • Alberta Children's Hospital, University of Calgary
Walter Eppich
  • Northwestern University