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Mannequin-Based Simulators and Part-Task Trainers
Abstract
Mannequin simulators and task trainers have become an essential part of simulation in anesthesiology. High-fidelity mannequin simulators heighten the physical and emotional fidelity of simulations by eliciting realistic physical exam findings and mimicking changes in physiology related to the scenario. Much research and development has gone into this technology, starting from very simple, low-fidelity cardiopulmonary resuscitation simulators to wireless, tetherless, complex mannequins capable of mimicking a myriad of patient signs and symptoms. Task trainers are simulation devices aimed at teaching one focused skill or procedure. Examples of these include difficult airway trainers, central venous access trainers, and neuraxial anesthesia trainers. These often serve as stand-alone resources; however, manufacturers are increasingly integrating these into high-fidelity mannequins. In this chapter, we review the history of mannequin simulators, evidence behind their use, contemporary examples, and future directions in the field.
... These are frequented by subspecialties that recognize the benefit of deliberate practice to obtain mastery in technical, procedural, or psychomotor skills. 22 Advanced part-task trainers with haptic feedback (ie, creating an experience of touch by applying force, vibration or movement in response to user operation) are being increasingly accepted in interventional and surgical training specialties such as general surgery, urology, gynecology, orthopedics and etc. 22 High fidelity simulators are sophisticated, lifelike mannequins capable of mimicking various physiological responses and medical conditions. These simulators allow learners to practice procedures such as intubation, chest tube insertion, and advanced cardiac life support in a realistic setting. ...
... These are frequented by subspecialties that recognize the benefit of deliberate practice to obtain mastery in technical, procedural, or psychomotor skills. 22 Advanced part-task trainers with haptic feedback (ie, creating an experience of touch by applying force, vibration or movement in response to user operation) are being increasingly accepted in interventional and surgical training specialties such as general surgery, urology, gynecology, orthopedics and etc. 22 High fidelity simulators are sophisticated, lifelike mannequins capable of mimicking various physiological responses and medical conditions. These simulators allow learners to practice procedures such as intubation, chest tube insertion, and advanced cardiac life support in a realistic setting. ...
Simulation-based education, is a relatively new approach, for practice and learning to develop healthcare professionals’ knowledge, skills, and attitudes, with different simulation modalities. This educational strategy is used to achieve adequate command in learning on preselected, programmed real-life or near-real-life clinical scenarios, avoiding undesirable features encountered or confronted in learning with real patients and undue stress to real patients within a safe learning environment. This editorial aimed to give a general overview of simulation in healthcare education. A brief history, the healthcare simulation concept and challanges of this training modality mentioned in the highlights of relevant references. Simulation based education has emerged as a transformative approach, significantly enhancing healthcare professionals’ learning experience and clinical competency. The various types of simulations offer a safe and controlled environment for participants to practice and hone technical and non-technical skills, ultimately improving patient safety and clinical outcomes. The integration of simulation with other training modalities and its adoption in diverse global contexts highlight its potential to revolutionize medical education worldwide.
... [1][2][3][4] The most common anesthesia simulations involve face-toface activities employing task trainers, "in-situ simulation" in actual operating rooms, and computer-driven electromechanical mannequins in mock operating rooms. 5 In recent years, screen-based simulation (SBS) using digital technology to represent patient scenarios on visual display units has played an escalating role in anesthesia education. [6][7][8] SBS constitutes the overlap of high-fidelity simulation with computer-based learning. ...
Purpose
The aim of the present study was to evaluate the feasibility, acceptability, and utility of synchronous online screen-based simulation (SBS) in anesthesia education.
Methods
The investigational cohort consisted of 12 second-year nurse anesthesia students enrolled in a Doctor of Nursing Practice (DNP) program. Pairs of students worked with a single instructor online using the same SBS employing a cloud-based peer-to-peer platform and high-fidelity software involving a graphical avatar. During each session, the instructor initially manipulated the avatar through the software scenario with educational pauses to communicate learning content. Thereafter, students proceeded through the same SBS by stating their desired actions, which were then implemented by the instructor. At the conclusion of each session, students were evaluated by an integrated software scoring system, and thereafter they completed a questionnaire rating their distance SBS experience.
Results
Synchronous online SBS was performed in this manner without difficulty; it was accepted by students as a valuable adjunct to their in-person mannequin-based simulation (MBS) training; and it was perceived as a useful addition to their anesthesia education. Students identified significant value in the isolation of the cognitive component of learning by this teaching methodology. Lack of haptic learning, however, also was seen as a disadvantage of SBS compared to MBS. Students’ criticisms of SBS were largely unrelated to use of this technique with synchronous online education, but rather related to general limitations associated with SBS technology. There was a positive correlation between the students’ mean post-SBS rating and the automated SBS score (r = 0.832).
Conclusion
Synchronous online SBS can effectively supplement MBS in an anesthesia training program. Its major perceived advantage appears to be an ability to isolate and reinforce appropriate cognitive skills related to intraoperative care including crisis management. Students who had higher mean post-SBS ratings also had higher automated SBS scores.
Background
Instructor-led synchronous screen-based simulation (SBS) allows distance teaching in anesthesia without the need for students to learn complex software but sacrifices experiential learning.
Methods
A total of 14 nurse anesthesia students performed a limited online instructor-led synchronous SBS followed by self-directed asynchronous sessions (synchronous-asynchronous SBS). We compared the outcome measures, post-activity questionnaires and integrated-software performance scores, from this group with identical evaluations from a previous cohort who participated only in instructor-led synchronous SBS with the same digital scenario.
Results
Students preferred synchronous-asynchronous SBS sessions compared to instructor-led synchronous SBS sessions, perceived the educational value of experiential learning in the former sessions, and rated them as less stressful. Performances were similar with both methods of instruction. Students rapidly acquired self-assessed proficiency with a complex, high-fidelity software program.
Conclusions
Synchronous-asynchronous SBS is preferable to instructor-led synchronous SBS because the former process permits experiential learning and is less stressful, and is associated with comparable performance scores. Proficiency was readily achieved with self-directed asynchronous SBS using a high-fidelity software program.
Videolaryngoscopy is often reserved for ‘anticipated’ difficult airways, but thereby can result in a higher overall rate of complications. We observed 65 anaesthetists, 67 residents in anaesthesia, 56 paramedics and 65 medical students, intubating the trachea of a standardised manikin model with a normal airway using seven devices: Macintosh classic laryngoscope, Airtraq®, Storz C-MAC®, Coopdech VLP-100®, Storz C-MAC D-Blade®, GlideScope Cobalt®, McGrath Series5® and Pentax AWS®) in random order. Time to and proportion of successful intubation, complications and user satisfaction were compared. All groups were fastest using devices with a Macintosh-type blade. All groups needed significantly more attempts using the Airtraq and Pentax AWS (all p < 0.05). Devices with a Macintosh-type blade (classic laryngoscope and C-MAC) scored highest in user satisfaction. Our results underline the importance of variability in device performance across individuals and staff groups, which have important implications for which devices hospital providers should rationally purchase.
There have been colossal technological advances in the use of simulation in anesthesiology in the past 2 decades. Over the years, the use of simulation has gone from low fidelity to high fidelity models that mimic human responses in a startlingly realistic manner, extremely life-like mannequin that breathes, generates E.K.G, and has pulses, heart sounds, and an airway that can be programmed for different degrees of obstruction. Simulation in anesthesiology is no longer a research fascination but an integral part of resident education and one of ACGME requirements for resident graduation. Simulation training has been objectively shown to increase the skill-set of anesthesiologists. Anesthesiology is leading the movement in patient safety. It is rational to assume a relationship between simulation training and patient safety. Nevertheless there has not been a demonstrable improvement in patient outcomes with simulation training. Larger prospective studies that evaluate the improvement in patient outcomes are needed to justify the integration of simulation training in resident education but ample number of studies in the past 5 years do show a definite benefit of using simulation in anesthesiology training. This paper gives a brief overview of the history and evolution of use of simulation in anesthesiology and highlights some of the more recent studies that have advanced simulation-based training.
To evaluate medical students' satisfaction with simulation based learning strategy (SBL).
A cross-sectional survey was conducted between October and November 2013 at the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. All third and fourth year medical students (n=185) both males and females were included. A self-developed questionnaire on the effect of SBL was used. Items included were related to knowledge, skill, environment, resources, and faculty. The questionnaire was validated by an expert reviewer, and the reliability was calculated for all the questionnaire items. Responses were measured on a 5 point Likert-type scale, and statistical analysis was carried out.
The response rate for this study was 62% (n=115). The alpha coefficient for all items was 0.73. Overall, respondents from both years' students were satisfied with teaching strategy, use of mannequins, and learning environment. The challenges reported were lack of skill-laboratories facilities, students' cooperation, allocated time for skill-laboratories, and knowledge of instructor. There was a small, but significant difference between the satisfaction scores among genders (p=0.001). Whereas no difference was identified between the participants' scores on satisfaction with SBL and year of education (p=0.62).
Although there were few challenges, most of the students were satisfied that SBL improved their knowledge retention, skills, and communication.
BACKGROUND AND OBJECTIVES: The use of ultrasound imaging in peripheral nerve block has been increasing. However, there are few reports in the literature on the learning curve of the ultrasound technique. The objective of this report was to evaluate the learning curve of CET-SMA/HSL Anesthesiology residents of ultrasound-guided peripheral block using an experimental agar model. METHODS: An experimental model was developed by filling a bowl with agar and olives. Nine residents were randomly divided in three groups (G1, G2, and G3), each one with a R1, a R2, and a R3. All three groups received theoretical explanation. G1 also had two hours of practical training, G2 had one hour, and G3 had no training. Residents were then asked to place a needle at the middle of the olive wall, near the transducer, and then reposition the needle between the olive and the bottom of the bowl, simulating the epidural injection of anesthetic. The speed and efficacy of the tasks, as well as technical flaws, were evaluated. RESULTS: The mean length of time to perform the tasks was 37.63 seconds for G1, without technical flaws; 64.40 seconds for G2, with two technical flaws; and 93.83 seconds for G3, with 12 technical flaws. CONCLUSIONS: This study allows us to conclude that the longer training of ultrasound-guided peripheral nerve block in an experimental model improved the learning curve of the technique.
Simulation for medical and healthcare applications, although still in a relatively nascent stage of development, already has a history that can inform the process of further research and dissemination. The development of mannequin simulators used for education, training, and research is reviewed, tracing the motivations, evolution to commercial availability, and efforts toward assessment of efficacy of those for teaching cardiopulmonary resuscitation, cardiology skills, anaesthesia clinical skills, and crisis management. A brief overview of procedural simulators and part-task trainers is also presented, contrasting the two domains and suggesting that a thorough history of the 20+ types of simulator technologies would provide a useful overview and perspective. There has been relatively little cross fertilisation of ideas and methods between the two simulator domains. Enhanced interaction between investigators and integration of simulation technologies would be beneficial for the dissemination of the concepts and their applications.
1969 to 2003, 34 years.
Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus.
Review and synthesize existing evidence in educational science that addresses the question, 'What are the features and uses of high-fidelity medical simulations that lead to most effective learning?'.
The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the 'grey literature' were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality.
Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention.
Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol.
Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. HEADLINE RESULTS: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following: providing feedback--51 (47%) journal articles reported that educational feedback is the most important feature of simulation-based medical education; repetitive practice--43 (39%) journal articles identified repetitive practice as a key feature involving the use of high-fidelity simulations in medical education; curriculum integration--27 (25%) journal articles cited integration of simulation-based exercises into the standard medical school or postgraduate educational curriculum as an essential feature of their effective use; range of difficulty level--15 (14%) journal articles address the importance of the range of task difficulty level as an important variable in simulation-based medical education; multiple learning strategies--11 (10%) journal articles identified the adaptability of high-fidelity simulations to multiple learning strategies as an important factor in their educational effectiveness; capture clinical variation--11 (10%) journal articles cited simulators that capture a wide variety of clinical conditions as more useful than those with a narrow range; controlled environment--10 (9%) journal articles emphasized the importance of using high-fidelity simulations in a controlled environment where learners can make, detect and correct errors without adverse consequences; individualized learning--10 (9%) journal articles highlighted the importance of having reproducible, standardized educational experiences where learners are active participants, not passive bystanders; defined outcomes--seven (6%) journal articles cited the importance of having clearly stated goals with tangible outcome measures that will more likely lead to learners mastering skills; simulator validity--four (3%) journal articles provided evidence for the direct correlation of simulation validity with effective learning.
While research in this field needs improvement in terms of rigor and quality, high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings.
Introduction:
The performance of laryngoscopes that have been developed for difficult airways can vary widely. The aim of the study was to compare Macintosh, McCoy, McGrath MAC, and C-MAC laryngoscopes in cervical immobilization and tongue edema scenarios in a mannequin, primarily to evaluate the time to intubation.
Methods:
In this randomized crossover study, 41 anesthesiology residents used 4 laryngoscopes in a mannequin (SimMan 3G) in 2 different scenarios. Intubation time (insertion of the blade between the teeth, to placement of the endotracheal tube into the trachea) longer than 120 seconds or inability to successfully place the endotracheal tube into the trachea after 5 or more attempts was defined as intubation failure. Besides intubation time, laryngoscopic view, number of intubation attempts, presence of esophageal intubation, need for stylet, difficulty of intubation, and success rate were recorded as secondary outcomes.
Results:
Intubation time was observed from longest to shortest as McGrath > McCoy > C-MAC > Macintosh in both scenarios. Laryngeal view was better with C-MAC laryngoscope. McGrath laryngoscope performed poorly specifically in tongue edema scenarios, which resulted in higher number of intubation attempts, esophageal intubation, need for intubation stylets, and overall intubation failure.
Conclusions:
The short intubation time observed with the Macintosh underlines the necessity of familiarity in success. Tongue edema is a more challenging scenario for simulated difficult airway and the McGrath may not be a good choice for such a scenario.
Thoracic anesthesia procedures are challenging to master during anesthesia training. A Laerdal ALS Simulator® manikin was modified by adding a bronchial tree module to create fidelity to the fourth generation. After modification, placement of endotracheal tubes up to 8.0 mm is possible by direct laryngoscopy, video laryngoscopy, and fiberoptically; in addition, it allows fiberoptically guided insertion of endobronchial blockers. Insertion of left and right 35-Fr double-lumen tubes permits double- and single-lung ventilation with continuous positive airway pressure and positive end-expiratory pressure. This anatomical modification created a high-fidelity training tool for thoracic anesthesia that has been incorporated into educational curricula for anesthesia.
Objectives
The objective of this study was to evaluate the effectiveness of high versus low fidelity manikins in the context of advanced life support training for improving knowledge, skill performance at course conclusion, skill performance between course conclusion and one year, skill performance at one year, skill performance in actual resuscitations, and patient outcomes.
Methods
A systematic search of Pubmed, Embase and Cochrane databases was conducted through Jan 31, 2014. We included two-group non-randomized and randomized studies in any language comparing high vs. low fidelity manikins for advanced life support training. Reviewers worked in duplicate to extract data on learners, study design, and outcomes. The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the overall quality of evidence for each outcome.
Results
3840 papers were identified from the literature search of which 14 were included (13 randomized controlled trials; 1 non-randomized controlled trial). Meta-analysis of studies reporting skill performance at course conclusion demonstrated a moderate benefit for high fidelity manikins when compared with low fidelity manikins [Standardized Mean Difference 0.59; 95% CI 0.13 to 1.05]. Studies measuring skill performance at one year, skill performance between course conclusion and one year, and knowledge demonstrated no significant benefit for high fidelity manikins.
Conclusion
The use of high fidelity manikins for advanced life support training is associated with moderate benefits for improving skills performance at course conclusion. Future research should define the optimal means of tailoring fidelity to enhance short and long term educational goals and clinical outcomes.
Results of recent attitude survey studies suggest that most practicing physicians are inadequately treating postoperative pain. Residents in anesthesia are confident in performing lumbar epidural and spinal anesthesia, but many are not confident in performing the blocks with which they have the least exposure. Changes need to be made in the training processes to a comprehensive model that prepares residents to perform a wider array of blocks in postgraduate practice. Here, we describe one institution's approach to creating a standardized, advanced regional anesthesia curriculum for residents that follows the six core competencies of the ACGME. Residents received training in anatomy dissection, ultrasound-guided regional anesthesia, traditional nerve stimulation techniques, problem-based learning and simulation sessions, oral board presentation sessions, and journal club sessions. Residents kept a detailed log for their use of peripheral nerve block procedures. We have now redesigned and implemented an advanced regional anesthesia program within our institution to provide residents with experience in regional anesthesia at a competent level. Resident's knowledge in regional anesthesia did improve after the first year of implementation as reflected in improvements between the pre- and post-tests. As the advanced regional anesthesia education program continues to improve, we hope to demonstrate levels of validity, reliability, and usability by other programs.
Flexible fibreoptic intubation (FOI) is a key element in difficult airway management. Training of FOI skills is an important part of the anaesthesiology curriculum. Simulation-based training has been shown to be effective when learning FOI, but the optimal structure of the training is debated. The aspect of dividing the training into segments (part-task training) or assembling into one piece (whole-task training) has not been studied.
The aims of this study were to compare the effect of training the motor skills of FOI as part-task training or as whole-task training and to relate the performance levels achieved by the novices to the standard of performance of experienced FOI practitioners.
A randomised controlled study.
Centre for Clinical Education, University of Copenhagen and the Capital Region of Denmark, between January and April 2013.
Twenty-three anaesthesia residents in their first year of training in anaesthesiology with no experience in FOI, and 10 anaesthesia consultants experienced in FOI.
The novices to FOI were allocated randomly to receive either part-task or whole-task training of FOI on virtual reality simulators. Procedures were subsequently trained on a manikin and assessed by an experienced anaesthesiologist. The experienced group was assessed in the same manner with no prior simulation-based training.
The primary outcome measure was the score of performance on testing FOI skills on a manikin.
A positive learning effect was observed in both the part-task training group and the whole-task training group. There was no statistically significant difference in final performance scores of the two novice groups (P = 0.61). Furthermore, both groups of novices were able to improve their skill level significantly by the end of manikin training to levels comparable to the experienced anaesthesiologists.
Part-task training did not prove more effective than whole-task training when training novices in FOI skills. FOI is very suitable for simulation-based training and segmentation of the procedure during training is not necessary.
Background
The percentage of women undergoing cesarean delivery under general anesthesia has significantly decreased, which limits training opportunities for its safe administration. The purpose of this study was to evaluate how effective simulation-based training was in the learning and long term retention of skills to perform general anesthesia for an emergent cesarean delivery.
Methods
During an eight-week obstetric anesthesia rotation, 24 residents attended lectures and simulation based training to perform general anesthesia for emergent cesarean delivery. Performance assessments using a validated weighted scaling system were made during the first (pre-test) and fifth weeks (post-test) of training, and eight months later (post-retention test). Resident’s competency level (weighted score) and errors were assessed at each testing session. Six obstetric anesthesia attending physicians, unfamiliar with the simulation scenario, generated a mean attendings’ performance score. The results were compared.
Results
At one week of training, residents’ performance was significantly below mean attendings’ performance score (pre-test: 135 ± 22 vs. 159.5 ± 11, P = 0.013). At five weeks, residents’ performance was similar to mean attendings’ performance score (post-test: 159 ± 21) and remained at that level at eight months (post-retention test = 164 ± 16). Of the important obstetric-specific tasks, left uterine displacement was missed by 46% of residents at eight months.
Conclusion
Following lectures and simulation-enhanced training, anesthesia residents reached and retained for up to eight months a competency level in a simulator comparable to that of obstetric anesthesia attending physicians. Errors in performance and missed tasks may be used to improve residency training and continuing medical education.
To determine the effectiveness of a short educational video and simulation on improvement of ultrasound (US) image acquisition and interpretation skills.
Prospective, randomized study.
University medical center.
28 anesthesia residents and community anesthesiologists with varied ultrasound experience were randomized to teaching video with interactive simulation or sham video groups.
Participants were assessed preintervention and postintervention on their ability to identify the sciatic nerve and other anatomic structures on static US images, as well as their ability to locate the sciatic nerve with US on live models.
Pretest written test scores correlated with reported US block experience (Kendall tau rank r = 0.47) and with live US scanning scores (r = 0.64). The teaching video and simulation significantly improved scores on the written examination (P < 0.001); however, they did not significantly improve live US scanning skills.
A short educational video with interactive simulation significantly improved knowledge of US anatomy, but failed to improve hands-on performance of US scanning to localize the nerve.
Transesophageal echocardiography (TEE) is a complex endeavor involving both motor and cognitive skills. Current training requires extended time in the clinical setting. Application of an integrated approach for TEE training including simulation could facilitate acquisition of skills and knowledge.
Echo-naive nonattending anesthesia physicians were offered Web-based echo didactics and biweekly hands-on sessions with a TEE simulator for 4 weeks. Manual skills were assessed weekly with kinematic analysis of TEE probe motion and compared with that of experts. Simulator-acquired skills were assessed clinically with the performance of intraoperative TEE examinations after training. Data were presented as median (interquartile range).
The manual skills of 18 trainees were evaluated with kinematic analysis. Peak movements and path length were found to be independent predictors of proficiency (P < 0.01) by multiple regression analysis. Week 1 trainees had longer path length (637 mm [312 to 1,210]) than that of experts (349 mm [179 to 516]); P < 0.01. Week 1 trainees also had more peak movements (17 [9 to 29]) than that of experts (8 [2 to 12]); P < 0.01. Skills acquired from simulator training were assessed clinically with eight additional trainees during intraoperative TEE examinations. Compared with the experts, novice trainees required more time (199 s [193 to 208] vs. 87 s [83 to 16]; P = 0.002) and performed more transitions throughout the examination (43 [36 to 53] vs. 21 [20 to 23]; P = 0.004).
A simulation-based TEE curriculum can teach knowledge and technical skills to echo-naive learners. Kinematic measures can objectively evaluate the progression of manual TEE skills.
The effectiveness of simulation is rarely evaluated. The aim of this study was to assess the impact of a short training course on the ability of anesthesiology residents to comply with current difficult airway management guidelines.
Twenty-seven third-year anesthesiology residents were assessed on a simulator in a "can't intubate, can't ventilate" scenario before the training (the pretest) and then randomly 3, 6, or 12 months after training (the posttest). The scenario was built so that the resident was prompted to perform a cricothyrotomy. Compliance with airway management guidelines and the cricothyrotomy's duration and technical quality were assessed as a checklist score [0 to 10] and a global rating scale [7 to 35].
After training, all 27 residents (100%) complied with the airway management guidelines, compared with 17 (63%) in the pretest (P < 0.005). In the pretest and the 3-, 6-, and 12-month posttests, the median [range] duration of cricothyrotomy was respectively 117 s [70 to 184], 69 s [43 to 97], 52 s [43 to 76], and 62 s [43 to 74] (P < 0.0001 vs. in the pretest), the median [range] checklist score was 3 [0 to 7], 10 [8 to 10], 9 [6 to 10], and 9 [4 to 10] (P < 0.0001 vs. in the pretest) and the median [range] global rating scale was 12 [7 to 22], 30 [20 to 35], 33 [23 to 35], and 31 [18 to 33] (P < 0.0001 vs. in the pretest). There were no significant differences between performance levels achieved in the 3-, 6-, and 12-month posttests.
The training session significantly improved the residents' compliance with guidelines and their performance of cricothyrotomy.
Standardized training via simulation as an educational adjunct may lead to a more rapid and complete skill achievement. The authors hypothesized that simulation training will also enhance performance in transesophageal echocardiography image acquisition among anesthesia residents.
A total of 42 clinical anesthesia residents were randomized to one of two groups: a control group, which received traditional didactic training, and a simulator group, whose training used a transesophageal echocardiography-mannequin simulator. Each participating resident was directed to obtain 10 commonly used standard views on an anesthetized patient under attending supervision. Each of the 10 selected echocardiographic views were evaluated on a grading scale of 0 to 10, according to predetermined criteria. The effect of the intervention was assessed by using a linear mixed model implemented in SAS 9.3 (SAS Institute Inc., Cary, NC).
Residents in the simulation group obtained significantly higher-quality images with a mean total image quality score of 83 (95% CI, 74 to 92) versus the control group score of 67 (95% CI, 58 to 76); P = 0.016. On average, 71% (95% CI, 58 to 85) of images acquired by each resident in the simulator group were acceptable for clinical use compared with 48% (95% CI, 35 to 62) in the control; P = 0.021. Additionally, the mean difference in score between training groups was the greatest for the clinical anesthesia-1 residents (difference 24; P = 0.031; n = 7 per group) and for those with no previous transesophageal echocardiography experience (difference 26; P = 0.005; simulator n = 13; control n = 11).
Simulation-based transesophageal echocardiography education enhances image acquisition skills in anesthesiology residents.
Even as simulation use in health care education has proliferated, there are terms used in simulation design that often lack clarity, in particular fidelity and cueing. To gain a better understanding of these terms, this article reports a systematic review of the literature for attributes and definitions of fidelity and cueing. Inclusion criteria included theoretical, educational, and empirical literature across disciplines that use simulation for educational or training purposes. Excluded w\ere publications with a nonhuman, noneducational, or primary or secondary school focus. Search strategies yielded 248 publications of which 13 met inclusion criteria. Results indicate fidelity is a multidimensional concept forming a matrix comprising physical, psychological, and conceptual dimensions. Cueing comprises two types, reality and conceptual cues, with mode of delivery enacted via equipment, environment, or patient and role characters. The article offers implications for simulation design considering the attributes of fidelity and cueing.
To perform a systematic review and meta-analysis of the literature on teaching airway management using technology-enhanced simulation.
We searched MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Web of Science, and Scopus for eligible articles through May 11, 2011.
Observational or controlled trials instructing medical professionals in direct or fiberoptic intubation, surgical airway, and/or supraglottic airway using technology-enhanced simulation were included. Two reviewers determined eligibility.
Study quality, instructional design, and outcome data were abstracted independently and in duplicate.
Of 10,904 articles screened, 76 studies were included (n = 5,226 participants). We used random effects meta-analysis to pool results. In comparison with no intervention, simulation training was associated with improved outcomes for knowledge (standardized mean difference, 0.77 [95% CI, 0.19-1.35]; n = 7 studies) and skill (1.01 [0.68-1.34]; n = 28) but not for behavior (0.52 [-0.30 to 1.34]; n = 4) or patient outcomes (-0.12 [-0.41 to 0.16]; n = 4). In comparison with nonsimulation interventions, simulation training was associated with increased learner satisfaction (0.54 [0.37-0.71]; n = 2), improved skills (0.64 [0.12-1.16]; n = 5), and patient outcomes (0.86 [0.12-1.59]; n = 3) but not knowledge (0.29 [-0.28 to 0.86]; n = 4). We found few comparative effectiveness studies exploring how to optimize the use of simulation-based training, and these revealed inconsistent results. For example, animal models were found superior to manikins in one study (p = 0.004) using outcome of task speed but inferior in another study in terms of skill ratings (p = 0.02). Five studies comparing simulators of high versus low technical sophistication found no significant difference in skill outcomes (p > 0.31). Limitations of this review include heterogeneity (I > 50% for most analysis) and variation in quality among primary studies.
Simulation-based airway management curriculum is superior to no intervention and nonsimulation intervention for important education outcomes. Further research is required to fine-tune optimal curricular design.
Ultrasound-guided regional anesthesia (UGRA) skills are traditionally obtained by supervised performance on patients, but practice on phantom models improves success. Currently available models are expensive or use perishable products, for example, olive-in-chicken breasts (OCB). We constructed 2 inexpensive phantom (transparent and opaque) models with readily available nonperishable products and compared the process of learning UGRA skills by novice practitioners on these models with the OCB model.
Three experts first established criteria for a satisfactory completion of the simulated UGRA task in the 3 models. Thirty-six novice trainees (<20 previous UGRA experience) were randomly assigned to perform a UGRA task on 1 of 3 models-the transparent, opaque, and OCB models, where the hyperechoic target was identified, a needle was advanced to it under ultrasound guidance, fluid was injected, and images were saved. We recorded the errors during task completion, number of attempts and needle passes, and the time for target identification and needle placement until the predetermined benchmark of 3 consecutive successful UGRA simulations was accomplished.
The number of errors, needle passes, and time for task completion per attempt progressively decreased in all 3 groups. However, failure to identify the target and to visualize the needle on the ultrasound image occurred more frequently with the OCB model. The time to complete simulator training was shortest with the transparent model, owing to shorter target identification times. However, trainees were less likely to agree strongly that this model was realistic for teaching UGRA skills.
Training on inexpensive synthetic simulation models with no perishable products permits learning of UGRA skills by novices. The OCB model has disadvantages of containing potentially infective material, requires refrigeration, cannot be used after multiple needle punctures, and is associated with more failures during simulated UGRA. Direct visualization of the target in the transparent model allows the trainee to focus on needle insertion skills, but the opaque model may be more realistic for learning target identification skills required when UGRA is performed on real patients in the operating room.
Training in transesophageal echocardiography (TEE) requires a significant commitment of time and resources on behalf of the trainees and the instructors. Training opportunities may be limited in the busy clinical environment. Medical simulation has emerged as a complementary means by which to develop clinical skills. Transesophageal echocardiography simulators have been commercially available for several years, yet their ability to distinguish experts from novices has not been demonstrated. We used a standardized assessment tool to distinguish experts from novices using a commercially available TEE simulator.
Anesthesiologists certified in advanced perioperative TEE and anesthesiology resident physicians were recruited into the expert and novice cohorts, respectively. The cohorts were recruited from 2 academic medical centers. The novice cohort received a structured introduction to the basic TEE examination. Both cohorts then proceeded to perform a basic TEE examination involving normal cardiac anatomy, which was evaluated by blinded raters using a standardized assessment tool.
The expert cohort consistently demonstrated the ability to obtain standard TEE imaging views in less time and more accurately than the novice cohort during the course of a simulated TEE examination.
A simulated transesophageal examination of normal cardiac anatomy in concert with a standardized assessment tool permits ample discrimination between expert and novice echocardiographers as defined for this investigation. Future research will examine in detail the role echocardiography simulators should play during echocardiography training including assessment of training level.
Complex epidural simulators are now available, but these are expensive and not widely available. Simple simulators using fruit have been described before.
To ascertain which easily available fruit would best simulate the 'feel' of loss of resistance experienced in epidural insertion and be used as a teaching tool.
A single blinded study using four different fruits housed in a purpose-built box to conceal the identities of the fruits. The fruits were labelled A, B, C and D.
Two teaching hospitals in Glasgow, Scotland between 2006 and 2007.
Fifty participants consisting of consultant anaesthetists, specialist registrars and senior house officers all with previous epidural experience.
Insertion of a Tuohy needle into the four concealed fruits (orange, banana, kiwi and honeydew melon). Each participant then completed a questionnaire that included recording of the realism of the 'feel' of loss of resistance of each fruit.
The 'feel' of loss of resistance for each fruit was scored on a 100-mm Visual Analogue Scale. A '0 mm' represented 'completely unrealistic feel' and '100 mm' represented 'indistinguishable feel from a real patient'.
A total of 62.6% of participants recorded the banana as their first choice. This result was statistically significant after taking into account the grades of the participants, their years of experience, the needle gauge used and the participants' chosen technique.
The banana is a cheap and easily available training tool to introduce novice anaesthetists to the feel of loss of resistance, which is best experienced before the first insertion of an epidural in a patient.
Background:
We are introducing a new epidural/spinal simulation unit to be used either as a part-task trainer to teach and learn regional anesthesia techniques or to be inserted in the manikin's back to allow reliable advanced simulation scenarios. The aim of this study was to determine if it may be a useful tool for training novice anesthesiologists in these procedures according to the evaluation performed by experienced anesthetists.
Methods:
Experienced anesthetists performed an epidural followed by a lumbar puncture procedure on the simulator model. Various aspects of both epidural and lumbar puncture insertions were scored for likeness to a real patient using a Likert scale.
Results:
Experienced anesthetists found the simulator to be life-like for almost all the aspects of epidural or spinal insertion and that the overall impression was that the simulator could provide a useful tool for training of epidural and spinal techniques. Almost all the examiners appreciated that this device contained layers representing the anatomical boundaries of each compartment, and the module can be added blood or sponge to the epidural compartment or water to the spinal compartment to challenge the trainee with more difficult procedure such as inadvertent dural or vascular puncture or difficult catheter insertion.
Conclusion:
This device to be inserted in a full scale manikin may be a promising tool for training of neuraxial procedures. It could be also an essential component of more complex high fidelity scenarios when neuraxial anesthesia is one of the major learning goals.
High-fidelity simulators have enjoyed increasing popularity despite costs that may approach six figures. This is justified on the basis that simulators have been shown to result in large learning gains that may transfer to actual patient care situations. However, most commonly, learning from a simulator is compared with learning in a 'no-intervention' control group. This fails to clarify the relationship between simulator fidelity and learning, and whether comparable gains might be achieved at substantially lower cost.
This analysis was conducted to review studies that compare learning from high-fidelity simulation (HFS) with learning from low-fidelity simulation (LFS) based on measures of clinical performance.
Using a variety of search strategies, a total of 24 studies contrasting HFS and LFS and including some measure of performance were located. These studies referred to learning in three areas: auscultation skills; surgical techniques, and complex management skills such as cardiac resuscitation.
Both HFS and LFS learning resulted in consistent improvements in performance in comparisons with no-intervention control groups. However, nearly all the studies showed no significant advantage of HFS over LFS, with average differences ranging from 1% to 2%.
The factors influencing learning, and the reasons for this surprising finding, are discussed.
Background
Simulation has been shown to be effective in teaching complex emergency procedural skills. However, the retention of these skills for a period of up to 1 yr has not been studied. We aimed to investigate the 6 month and 1 yr retention of the complex procedural skill of cricothyroidotomy in attending anaesthetists using a high-fidelity-simulated cannot intubate, cannot ventilate (CICV) scenario.
Methods
Thirty-eight attending anaesthetists participated individually in a high-fidelity-simulated CICV scenario (pretest) that required a cricothyroidotomy for definitive airway management. Immediately after a debriefing and structured teaching session on cricothyroidotomy insertion, subjects managed a second identical CICV scenario (post-test). Each anaesthetist was randomized to either a ‘6 month retention' or a ‘12 month retention' group. No further teaching occurred. At their respective retention times, each anaesthetist managed a third identical CICV scenario (retention post-test). Two blinded experts independently rated videos of all performances in a random order, using a specific checklist (CL) score, a global-rating scale (GRS) score, and procedural time (PT).
Results
Subjects from both groups improved on their cricothyroidotomy skill performances from pretest to immediate post-test and from pretest to retention post-test, irrespective of the retention interval; CL mean (sd) 8.00 (2.39) vs 8.88 (1.53), P=0.49; GRS 28.00 (7.80) vs 31.25 (5.31), P=0.25; PT 102.83 (63.81) s vs 106.88 (36.68) s, P=0.73.
Conclusions
After a single simulation training session, improvements in cricothyroidotomy skills are retained for at least 1 yr. These findings suggest that high-fidelity simulation training, along with practice and feedback, can be used to maintain complex procedural skills for at least 1 yr.
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.
Epidural anesthesia is a technically challenging regional anesthetic technique that can be difficult to teach to novices. Epidural simulators are now available to allow realistic training within a safe and controlled environment before attempting the procedure on patients. Potentially, this may improve skill acquisition by novice residents. The purpose of this study was to examine the effect of a high-fidelity epidural anesthesia simulator on residents' ability to perform their first labor epidurals and on their learning curve compared with a group having training with a low-fidelity model.
Second-year anesthesia residents were recruited. Subjects were randomized into 2 groups and practiced epidural needle insertion on a high-fidelity epidural simulator or on a low-fidelity model. Subjects were then repeatedly videotaped performing epidural anesthesia over a 6-month period. Two blinded examiners graded each session, using a previously validated Global Rating Scale and Manual Skill Checklist to judge the skill level.
Seventy-two sessions performed by 24 residents were recorded. Manual Skill Checklist and Global Rating Scale total scores were compared across the 2 study groups at baseline (first epidural), middle (31-90 epidurals) and late (>90 epidurals) time points using independent-samples t tests. No significant differences in scores were detected at either one of these time points.
Our study shows that a simple model can be as useful for learning how to place an epidural catheter as an expensive anatomically correct simulator. New and more technologically advanced simulators should be compared against lower fidelity models to establish their utility and cost-effectiveness.
Previous studies have indicated that fiberoptic orotracheal intubation (FOI) skills can be learned outside the operating room. The purpose of this study was to determine which of two educational interventions allows learners to gain greater capacity for performing the procedure.
Respiratory therapists were randomly assigned to a low-fidelity or high-fidelity training model group. The low-fidelity group was guided by experts, on a nonanatomic model designed to refine fiberoptic manipulation skills. The high-fidelity group practiced their skills on a computerized virtual reality bronchoscopy simulator. After training, subjects performed two consecutive FOIs on healthy, anesthetized patients with predicted "easy" intubations. Each subject's FOI was evaluated by blinded examiners, using a validated global rating scale and checklist. Success and time were also measured.
Data were analyzed using a two-way mixed design analysis of variance. There was no significant difference between the low-fidelity (n = 14) and high-fidelity (n = 14) model groups when compared with the global rating scale, checklist, time, and success at achieving tracheal intubation (all P = not significant). Second attempts in both groups were significantly better than first attempts (P < 0.001), and there was no interaction between "fidelity of training model" and "first versus second attempt" scores.
There was no added benefit from training on a costly virtual reality model with respect to transfer of FOI skills to intraoperative patient care. Second attempts in both groups were significantly better than first attempts. Low-fidelity models for FOI training outside the operating room are an alternative for programs with budgetary constraints.
Simulation is used extensively in industries that involve routine, but risky activities. The authors describe an anesthesia simulation environment that provides a re-creation of the anesthesiologist's task environment in a real operating room. The system provides appropriate inputs to standard monitoring equipment in common use during anesthesia, including ECG (with arrhythmias); invasive systemic arterial, pulmonary arterial, and central venous pressures (all coupled to ECG arrhythmias); automated cuff blood pressure; pulse oximetry; mass spectrometry; breathing circuit spirometry; and oxygen analysis. An intubation/thorax mannequin allows tracheal intubation and tube manipulation, and provides for simulation of occlusion, malposition, or disconnection of the tracheal tube, as well as regurgitation of gastric contents. The simulation is comprehensive in that it is "hands-on" and requires actual performance of most interventions using actual equipment. The simulation is conducted by a systems operator and a simulation director; the latter also acts in the roles of surgeon and circulating nurse. The simulator outputs are determined by a "script" that defines the consequences of routine anesthetic actions and pre-established critical incidents. Decisions about timing and override of the script are made by the simulation director. This control system offers maximum flexibility while maintaining clinical realism. The simulator experiences were judged as highly realistic by 21 subjects. Limitations in this version have centered on the mannequin (e.g., no patient movement, minimal or confusing physical signs) and will be addressed in future versions of the system. The authors suggest that anesthesia simulation can be accomplished at nominal expense and has major potential for training, continuing education, certification, and research.
A total of 208 fourth-year students at five medical schools participated in an evaluation of a cardiology patient simulator (CPS). One group (116 students) used the CPS during a fourth-year cardiology elective, while another group (92 students) completed a cardiology elective that did not include use of the CPS. There were no differences between the two groups on a multiple-choice test on cardiology and a skills test on the CPS at the beginning of the clerkship. After the clerkship, the students in the CPS group achieved significantly higher scores on a multiple-choice test, a skills test on the CPS, and a skills test on cardiology patients. Both the students and faculty members expressed very favorable attitudes toward the CPS, but the patients perceived no differences between the two student groups. These data demonstrate that the CPS enhances learning both the knowledge and the skills necessary to perform a bedside cardiovascular evaluation and that the skills obtained from use of the simulator are transferable to use with patients.
The final prototype of "Harvey," a cardiology patient simulator, was completed in 1976. A review and critique of the simulator's nonauscultatory and auscultatory physical findings by cardiologists indicated that the simulator was capable of faithfully reproducing the blood pressure, jugular venous pulsations, carotid and peripheral arterial pulsations, precordial impulses and auscultatory events of almost all cardiac diseases. Pilot studies using the simulator in a formal senior medical student elective program in cardiology showed an average gain in bedside examination skills of 32 percent (p < 0.01). This improvement occurred with as little as 1 hour of instructor time with students studying eight simulated cardiac disease states and associated slide material for 1 hour per disease over a 2 week period in a self-teaching format. To assess the acceptability of the device, 770 undergraduate and graduate physicians, family practitioners, internists and cardiologists were exposed to the cardiology patient simulator. Their reaction was positive, 93 percent rating it excellent and 100 percent wishing to be taught with the device again in the future. Prolonged periods of use demonstrated the technical reliability of the simulator. Formal multicenter studies are now underway that will assess its effectiveness as a teaching and testing device. The long range goals of these efforts remain: (1) to produce better trained physicians in less time and at less cost; and (2) to provide an objective method to measure the clinical competency and skills of students and physicians in patient-oriented examinations, such as those for Board certification and recertification.
The decrease in the percentage of patients having cesarean delivery during general anesthesia has led some educators to advocate the increased use of simulation-based training for this anesthetic. The authors developed a scoring system to measure resident performance of this anesthetic on the human patient simulator and subjected the system to tests of validity and reliability.
A modified Delphi technique was used to achieve a consensus among several experts regarding a standardized scoring system for evaluating resident performance of general anesthesia for emergency cesarean delivery on the human patient simulator. Eight third-year and eight first-year anesthesiology residents performed the scenario and were videotaped and scored by four attending obstetric anesthesiologists.
Third-year residents scored an average of 150.5 points, whereas first-year residents scored an average of 128 points (P = 0.004). The scoring instrument demonstrated high interrater reliability with an intraclass correlation coefficient of 0.97 (95% confidence interval, 0.94-0.99) compared with the average score.
The developed scoring tool to measure resident performance of general anesthesia for emergency cesarean delivery on the patient simulator seems both valid and reliable in the context in which it was tested. This scoring system may prove useful for future studies such as those investigating the effect of simulator training on objective assessment of resident performance.
The historical roots of simulation might be described with the broadest definition of medical simulation: "an imitation of some real thing, state of affairs, or process" for the practice of skills, problem solving, and judgment. From the first "blue box" flight simulator to the military's impetus in the transfer of modeling and simulation technology to medicine, worldwide acceptance of simulation training is growing. Large collaborative simulation centers support the expectation of increases in multidisciplinary, interprofessional, and multimodal simulation training. Virtual worlds, both immersive and Web-based, are at the frontier of innovation in medical education.
Advanced airway management simulation training in medical education
- C C Kennedy
- E K Cannon
- D O Warner
- D A Cook
- CC Kennedy
The Girl from the River Seine
- Inc Laerdal
Next Generation Harvey - The Cardiopulmonary Patient Simulator
- Inc Laerdal
Critical events simulation for training in anesthesiology
- M Good
- S Lampotang
History of Edward Link
- L S Training
Comparison of 4 laryngoscopes in 2 difficult airway scenarios
- D Altun
- T Ozkan-Seyhan
- M Orhan-Sungur
- N Sivrikoz
- E Camci