Gauging the effectiveness of brain-based learning and simulation in an airway management course for emergency medicine interns

Abstract

Airway management is a critical skill that emergency medicine (EM) residents must develop. Brain-based learning is a form of instruction that creates the best conditions for learning and retention. Used in conjunction with simula-tion-based instruction, the potential exists for reaching more learners. The purpose of this study was to assess the basic airway management skills of postgraduate year-one (PGY-1) EM residents before and after receiving training through a three-hour brain-based learning and simulation course in order to gauge the effectiveness of this teaching method. EM residents who completed a brain-based learning and simulation course in airway management in 2010 were evaluated be-fore and immediately after the course by using a multiple-choice quiz to assess knowledge and a standardized checklist to assess practical airway skills. Pretest and posttest assessments were identical and subjects were blinded to the practical assessment criteria. Mean pretest scores on the quizzes and practical skills assessments were calculated and compared with mean posttest scores using two-tailed paired t-tests. A total of 71 new EM residents participated in this study. Im-provements were observed in each practical airway management skill; mean total pretest score increased from 22.82/30 to a mean posttest score of 26.98/30 (p = 0.03). Improvements were also observed in knowledge assessments, from a mean pretest score of 5.97/10 to mean posttest score of 8.90/10 (p = 0.00). In conclusion, a three-hour brain-based learning and simulation course was effective at improving new EM residents’ knowledge and practical skills in basic airway management.

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Journal of Emergency & Disaster Medicine 1, 1 (2012) | Article
Gauging the Effectiveness of Brain-Based Learning and
Simulation Instruction in an Airway Management Course for
Emergency Medicine Residents
Timothy C. Clapper1, Timmy Li2, N. Seth Trueger3, Yasuharu Okuda4,5
1. College of Nursing, University of Texas at Arlington, Arlington, TX, USA
2. Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA
3. Department of Emergency Medicine, George Washington University, Washington, DC, USA
4. University of Central Florida College of Medicine, Orlando, FL, USA
5. SimLEARN, Veterans Health Administration, Orlando, FL, USA
*Corresponding author: Timmy Li, Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY,
USA (Email: TimLi246@gmail.com )
Abstract: Airway management is a critical skill that emergency medicine (EM) residents must develop. Brain-based
learning is a form of instruction that creates the best conditions for learning and retention. Used in conjunction with simula-
tion-based instruction, the potential exists for reaching more learners. The purpose of this study was to assess the basic
airway management skills of postgraduate year-one (PGY-1) EM residents before and after receiving training through a
three-hour brain-based learning and simulation course in order to gauge the effectiveness of this teaching method. EM
residents who completed a brain-based learning and simulation course in airway management in 2010 were evaluated be-
fore and immediately after the course by using a multiple-choice quiz to assess knowledge and a standardized checklist to
assess practical airway skills. Pretest and posttest assessments were identical and subjects were blinded to the practical
assessment criteria. Mean pretest scores on the quizzes and practical skills assessments were calculated and compared
with mean posttest scores using two-tailed paired t-tests. A total of 71 new EM residents participated in this study. Im-
provements were observed in each practical airway management skill; mean total pretest score increased from 22.82/30 to
a mean posttest score of 26.98/30 (p = 0.03). Improvements were also observed in knowledge assessments, from a mean
pretest score of 5.97/10 to mean posttest score of 8.90/10 (p = 0.00). In conclusion, a three-hour brain-based learning and
simulation course was effective at improving new EM residents’ knowledge and practical skills in basic airway management.
KEYWORDS: brain-based learning, simulation, airway management, medical education
Received: April 7, 2012, Accepted: April 20, 2012, Published: September 15th, 2012
A
irway management is a fundamental skill in emer-
gency medicine (EM).1 EM residents typically de-
velop proficiency in airway management during
residency through the apprenticeship model of
learning, which assumes that residents will encounter a vari-
ety of clinical situations during their residency that will allow
them to develop the skills necessary to handle future clinical
encounters. However, some residents may not have the op-
portunity to experience uncommon clinical situations with
sufficient frequency to develop the skills needed to handle
certain situations.2 Additionally, the apprenticeship model
requires inexperienced residents to perform clinical proce-
dures on patients in the clinical setting.3 This model does not
ensure that residents develop proficiency in practical skills
and places patients at risk for complications.4
Some high-risk, low-frequency clinical presentations re-
quire successful airway management as part of its manage-
ment.5 Because of the relative infrequency of patients requir-
ing airway management in the emergency department, it is
difficult to adequately teach EM residents airway manage-

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Timothy C. Clapper, et al.| Gauging the Effectiveness of Brain-Based Learning and Simulation Instruction in an Airway
Article
ment skills through apprenticeship alone. One study found
that the first time intubation success rate is 72% among first
year residents,1 which demonstrates the misunderstandings,
difficulties, and variance in technique associated with airway
management. Numerous studies have reported that many
clinicians are unable to state and apply the correct amount of
cricoid pressure,6,7 and many clinicians confuse cricoid pres-
sure, the BURP (Backward, Upward, Rightward Pressure)
maneuver, and external laryngeal manipulation.8 Careless-
ness and limited experience in laryngoscopy for intubation
and airway management can lead to permanent injuries or
death.9,10 Therefore, additional education and training is nec-
essary to enhance clinicians’ knowledge and skills in airway
management.
Simulation offers the potential to teach airway manage-
ment skills in a realistic and safe environment with ample
opportunities for practice. Direct instruction, especially an
over-reliance on didactic lectures, may not meet the learning
style preferences of many residents as they attempt to under-
stand the reasons for the use of particular airway skills. Fur-
ther, an instructor who relies on direct instruction alone may
have difficulty assessing learners’ understanding throughout
the instructional process. Lesson planning should coincide
with the way the brain acquires and processes information
into long-term memory.11 A four-phase lesson plan that com-
bines brain-based learning and differentiated instruction has
been proposed, utilizing the four phases: inquire, gather,
process, and apply.11 This four-phase lesson plan was modi-
fied for clinicians by one of the authors (T.C.C.) because the
design is compatible with the Accreditation Council for Gradu-
ate Medical Education’s (ACGME) six general competencies
that are important to the practice of medicine: 1) patient care,
2) medical knowledge, 3) interpersonal and communication
skills, 4) professionalism, 5) practice-based learning and im-
provement, and 6) systems-based practice. The ACGME
promotes the integration of a variety of learning and teaching
approaches focused on improving patient care outcomes.12
While the effectiveness of brain-based, differentiated in-
struction on various academic subjects has been examined,
we have not found studies that assessed the effectiveness of
brain-based simulation instruction on airway management
knowledge and skills. The purpose of this study was to as-
sess the airway management skills of new EM residents after
receiving brain-based simulation instruction in order to gauge
the effectiveness of this teaching method. We hypothesized
that residents’ airway management skills will improve after
receiving brain-based simulation instruction.
Material and Methods
Study Design
This was a pre- and post-educational intervention assess-
ment of starting postgraduate year one (PGY-1) EM residents
from four EM residency programs affiliated with the New York
City Health and Hospitals Corporation. Institutional review
board approval was obtained prior to conducting this study.
All residents were informed about the goals, risks, and bene-
fits of participating in the study, and written informed consent
was obtained.
Study Setting and Population
This study was conducted at four New York City Health
and Hospitals Corporation hospitals, each of which is an ur-
ban tertiary care center affiliated with a medical school and
separate university hospital. On average, each hospital ca-
res for approximately 110,000 patients annually (range
75,000-135,000). All starting PGY-1 residents from the EM
residency programs at the four hospitals were trained in air-
way management through a brain-based learning and simula-
tion course. All residents in the course were eligible to par-
ticipate in the study.
Study Protocol
In July 2010, 73 starting PGY-1 EM residents attended a
single three-hour basic airway management skills course with
brain-based learning and simulation. Prior to the start of the
course, study investigators (N.S.T. and/or T.L.) provided an
overview of the study, informed residents about the voluntary
nature of the study, and invited residents to participate in the
study. Written informed consent was obtained from the 71
residents who chose to participate in the study. All subjects
underwent pretesting before the start of the course. Subjects’
airway management skills and knowledge were evaluated
individually using two methods of assessment: 1) a written
quiz on knowledge of airway management and 2) a practical
assessment of airway management skills.
The written quiz consisted of ten multiple-choice questions
on airway management. Topics included: patient positioning,
laryngoscopy technique and complications, cricoid pressure,
laryngeal manipulation, and bag-mask-ventilation (BMV).
One point was awarded for each question answered cor-
rectly, for a maximum score of 10.
The practical skills assessment required subjects to dem-
onstrate oropharyngeal airway (OPA), nasopharyngeal air-
way (NPA), and BMV techniques, and perform endotracheal
intubation on a simulated airway (AirSim Bronchi Trainer,
Belfast, UK). Subjects’ performance was evaluated by a
study investigator using a checklist (T.L., N.S.T., or Y.O.).
One point was awarded for each criterion that was performed

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correctly without assistance. Subjects were blinded to the
testing criteria. The maximum score for the OPA skill was 6,
NPA 4, BMV 6, and intubation 14. The checklist was devel-
oped based on guidelines from the New York State Depart-
ment of Health, Bureau of Emergency Medical Services, as
well as a consensus discussion between study investigators.
As shown in Figure 1, the brain-based simulation instruc-
tion, designed and facilitated by one of the study investigators
(T.C.C.), commenced after pretesting was completed. The
course included assessment of residents’ knowledge, coop-
erative learning session of evidence-based topic reviews,
airway skills demonstration, technique practice time, and
group-based simulated airway management cases on a me-
dium-fidelity mannequin (ALS Simulator , Laerdal Medical
Corporation, Wappingers Falls, NY). Immediately after the
course, subjects were administered the posttest, which con-
sisted of the same two methods of assessment as the pre-
test: written quiz and practical skills assessment. The pri-
mary outcome measure of this study is the difference in
scores between the pretests and posttests.
Data Analysis
Pretest and posttest scores from the written quizzes and
practical skills assessments were computed and entered into
Predictive Analytics Software (PASW) for analysis; missing
data were imputed with mean values. Mean scores from the
pretests were compared with mean scores from the posttests
using two-tailed paired t-tests. The two-tailed paired t-test
was selected because it allows us to determine whether the
means of the pretests and posttests differ significantly from
each other. A p-value of < 0.05 was considered statistically
significant.
Results
A total of 71 residents participated in this study; 11 sub-
jects did not complete the practical skills assessment. As
shown in Table 1, the mean knowledge assessment score
increased from 6.0 to 8.9 after the course (p=0.00), and the
practical skills scores increased from 22.8 to 27.0 (p=0.03).
Discussion
Airway management is an important, fundamental skill for
EM physicians. The life-threatening and infrequent nature of
patient encounters requiring airway management makes
brain-based learning and simulation potentially invaluable
educational tools for teaching airway skills. In this study, we
demonstrated that PGY-1 EM residents significantly improved
their airway management knowledge and skills after a three-
hour brain-based learning and simulation instruction course.
This course incorporated the four-phase lesson plan, com-
bining brain-based learning and differentiated learning. In
each of the four phases, the learners were engaged in active
learning activities and a reflection-in-action process that as-
sist learners with moving through the transformative learning
process.13 Cooperative learning techniques are an important
part of the brain-based lesson plan. They are used to assist
learners with the declarative knowledge needed to under-
stand the procedural knowledge that follows. More than what
some might refer to as group work, cooperative-based learn-
ing techniques consist of groups of learners analyzing and
constructing knowledge with the assistance of the course
facilitator and other learners. Learners generally construct
knowledge both individually and with the help of others as
they internalize new information or information that is different
from their existing understanding.14,15
In addition, cooperative learning techniques allow for
movement and active participation that is important for learn-
ing through a person’s preferred learning styles. Multiple
meta-analyses have demonstrated the effectiveness of in-
structional techniques when the learning style needs of learn-
ers are met.16,17 The cooperative learning is followed by dem-
onstrations of the skills on partial-task simulators, which pro-
gress to practice, scaffolding, and positive feedback from the
facilitators. Following a reflection of learning, the learners are
placed in clinical simulation where they apply the skills and
Timothy C. Clapper, et al.| Gauging the Effectiveness of Brain-Based Learning and Simulation Instruction in an Airway
Article

Www.jedm.org; JEDM2012.6 | Page 2012.6- 4
knowledge acquired from the course. The debriefing, or re-
flection-on-action process that follows the simulation experi-
ence assists the learners with assessing how well they applied
the skills and how they will use them in the clinical setting. To
maximize the brain-based learning experience, it is important
to maintain positive emotions throughout the entire learning
process. This is accomplished by maintaining a learning envi-
ronment that is not threatening to the learner.13
We also utilized two different airway models in this course
– the AirSim Bronchi Trainer and the Laerdal ALS Simulator –
on which the residents were assessed, instructed, given
guided and independent practice time, and re-assessed.
Whereas real-world clinical education on actual patients offers
limited opportunities to practice individual airway skills, includ-
ing NPA and OPA placement, BMV, and laryngoscopy and
intubation, this simulated environment offers a safe environ-
ment where students can practice and hone their airway skills.
The improvement from pre- to post-course assessment indi-
cates that students were able to hone their skills, without plac-
ing patients at risk. Moreover, all participants had Basic Life
Support and Advanced Cardiac Life Support training, which
includes airway management training, yet demonstrated statis-
tically significant improvement in both skill and knowledge as a
result of this brain-based learning and simulation instruction
course.
This study has several limitations. As the primary assess-
ments were pre- and post-course student assessments, we
were not able to blind the evaluators. In addition, although the
practical skills assessment checklists were reviewed by sev-
eral emergency medicine clinicians, the checklists were cre-
ated by the study investigators as, to our knowledge, there are
no rigorously validated airway assessment instruments. Fur-
ther, although the assessment criteria were designed to be as
objective as possible, there is also potential for inter-rater vari-
ability.
This study evaluates the immediate improvement in airway
management skills, and does not assess long-term retention.
There was also no control group and therefore, our results
cannot be compared to other educational methods. Also, as
with any study of simulation, there may be limitations to real-
life clinical applications of the skills involved. W hile it seems
intuitive that clinical skills developed in a simulated environ-
ment can be extrapolated to real patient encounters, there is
certainly a debate about the extent or limitations of simulation
education. Finally, although this study involved residents from
multiple sites, the sample size makes it difficult to generalize
to the general population.
Conclusion
A three-hour brain-based simulation instruction course was
effective at improving the basic airway management knowl-
edge and skills of PGY-1 EM residents in a simulated environ-
ment. Future studies are needed to assess the retention of
skills and residents’ airway management skills in clinical en-
counters.
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Timothy C. Clapper, et al.| Gauging the Effectiveness of Brain-Based Learning and Simulation Instruction in an Airway
Article