Past decades have seen continuous changes in medical education, with patient safety becoming a point of emphasis and bedside training opportunities being limited by duty hour restrictions.1 Therefore, traditional training has been steadily augmented by simulation-based training (SBT), facilitating on-demand training without exposing patients to harm while offering trainees systematic and objective learning experiences.2
Graduating students and residents feel inadequately trained and lack the competency to appropriately manage medical emergencies.3,4 Thus, we have introduced an elective course (’The Graz’ SIMLine: Emergency Room’) aiming at engaging medical students in SBT in a simulated emergency department (SED). This study describes underlying concepts and key elements of the course and the methods used.
The course was offered to medical students who had previously participated in one of our elective courses, covering emergency management of patients with acute allergic reactions5 and cardiac diseases. These courses utilise similar instructional methodologies: seminars for theoretical introduction, workshop-based part-task training and dedicated SBT followed by video-assisted debriefing. Basic and advanced life support, electrical therapies (defibrillation, cardioversion, transcutaneous pacing), ECG interpretation, drug preparation and administration, vascular and intraosseous access, sedation, anaesthesia and airway management procedures (endotracheal intubation, laryngeal mask, cricothyrotomy) are practiced using part-task trainers and patient simulators. Screen-based simulation is used for the training of ABCDE assessment.
Prior to SED training, we offered 10 h of mandatory refresher training to ensure consistency of cognitive, technical and behavioural skills. Seminar topics included the review of procedural and treatment algorithms, 12-lead ECG analysis, common emergency drugs, sedation and anaesthesia, and intrahospital transport of critically ill patients. Principles of human failure and limitations, crisis resource management,6 effective team communication, strategies to improve patient safety (e.g. standard procedures, use of checklists), structured patient handover and delivery of bad news were discussed and practiced.
Approximately 800 square metres of our institution's lecture hall centre were adapted for the SED. Three resuscitation rooms were implemented using examination tables, patient monitors, resuscitation trolleys, syringe pumps, mechanical ventilators and anaesthesia machines. Five rooms were equipped for ambulatory care, and one lecture hall functioned as a conference room. The day before SED training, students received a two hour introduction to familiarise them with the training site and available equipment.
The course team comprised 20 individuals. The team aspect of the exercise was achieved by introducing three emergency physicians, one nurse, one patient transporter and one secretary as the SED's core faculty. Didactic personnel included one person responsible for the scenario schedule, two simulation operators, two persons preparing equipment according to scenarios and one technician. Five standardised patients and two simulated family members were recruited. A clinical psychologist was available as a precautionary measure, as acute stress reactions may possibly occur during such a demanding simulation session.
During SBT, three to four students acted as one medical emergency team, with three teams being on duty for 4 h each. Emergency medical services announced patients, and senior faculty coordinated clinical duties. Students were fully responsible for patient care and had to decide whether additional diagnostic studies were needed. Laboratory tests were available for all patients. After each patient encounter, students had to complete patient notes, including diagnoses, therapeutic interventions and recommendations. Critically ill patients had to be transferred to the remote ICU, and students were responsible for accompanying the patient. Every medical emergency team encountered at least three medical emergencies, had to take care of at least four standardised patients in the outpatient clinic and performed intra-hospital critical care transport at least once.
Scenarios featured acute emergencies, (semi-)elective admissions and in-patient complications. Acute emergencies were simulated using high-fidelity patient simulators, including firstly, a 23-year-old patient with anaphylactic reaction and progressive respiratory distress requiring cricothyrotomy, and secondly, a 59-year-old patient with acute bradycardia and hypotension due to third-degree atrioventricular block requiring transcutaneous pacing. Scenarios involving standardised patients and hybrid simulation comprised tasks such as blood sample taking after needle stick injuries, surgical treatment of lacerations and treatment of acute gastroenteritis.
Students who had completed at least one of our elective courses during the past 2 years were free to enrol via our institution's online course system. For postcourse evaluation, standard questionnaires of the Medical University of Graz were used, consisting of 25 items (six-point Likert scales, ‘1’ representing highest approval) with five of them asking for curriculum evaluation in general. Space was provided for comments. Data are given as means ± standard deviations.
Of 24 enrolled third-year students, 21 (87.5%) participated in all course parts. Twenty questionnaires (95.2%) were returned. The analysis indicated a high level of satisfaction: adequate utilisation of different didactic elements (1.2 ± 0.5), opportunities for active participation in training (1.2 ± 0.5), medical relevance of contents (1.0 ± 0.0), learning success (1.1 ± 0.2) and general satisfaction (1.1 ± 0.2).
Our project shows that an emergency department can be successfully simulated for educational purposes. We have used the SED concept for prior courses,5 but not to such an extent regarding the focus on crisis resource management aspects, the medical spectrum of presenting cases, the number of engaged standardised patients and the level of environmental and psychological fidelity, by utilising functional intensive care equipment and having students practice as part of an interdisciplinary team. Educational advantages include well defined learning objectives, curriculum integration, a range of different methods including SBT, deliberate practice, training in teams and feedback. This is in line with educational literature.7 The SED set-up, however, is resource intensive, requiring a collective effort from an enthusiastic team with sound experience in preparing and delivering SBT. Delivery of training in actual clinical areas and increased engagement of student peer-teachers may help reduce the organisational burden while improving course efficiency.
One might speculate whether this course is too advanced for third-year medical students. Does the benefit counterbalance the costs? The students were very satisfied with the course, but the effect on learning was not evaluated. The course might be more relevant for more senior students or residents. Hence as a next step, the course will be held regularly with a focus on more senior students in order to prepare them for future duties. Currently, we are also considering offering SED training to graduate faculty, as this may be one tool to improve preparedness of residents when having to care for critically ill patients.3
Acknowledgements relating to this article
Assistance with the letter: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
1. McLaughlin S, Fitch MT, Goyal DG, et al. Simulation in graduate medical education 2008: a review for emergency medicine. Acad Emerg Med
2. Cooper JB, Murray D. Simulation training and assessment: a more efficient method to develop expertise than apprenticeship. Anesthesiology
3. Hayes CW, Rhee A, Detsky ME, et al. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med
4. Jensen ML, Hesselfeldt R, Rasmussen MB, et al. Newly graduated doctors’ competence in managing cardiopulmonary arrests assessed using a standardized Advanced Life Support (ALS) assessment. Resuscitation
5. Mileder LP, Wegscheider T. Anaphylaxis management: a multimodal curriculum with a distinct focus on simulation-based training. Resuscitation
6. Boet S, Bould MD, Fung L, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Can J Anaesth
7. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003*-*2009. Med Educ